Provider Demographics
NPI:1003189762
Name:SCHAEFER, KENNETH (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:SCHAEFER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 LINDEN CT
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1683
Mailing Address - Country:US
Mailing Address - Phone:608-848-9142
Mailing Address - Fax:
Practice Address - Street 1:527 LINDEN CT
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1683
Practice Address - Country:US
Practice Address - Phone:608-848-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.028504183500000X
WI13413-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist