Provider Demographics
NPI:1033230149
Name:SPENCE, TINA MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:SPENCE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 KOZELEK RD
Mailing Address - Street 2:
Mailing Address - City:ROSHOLT
Mailing Address - State:WI
Mailing Address - Zip Code:54473-8969
Mailing Address - Country:US
Mailing Address - Phone:715-572-6791
Mailing Address - Fax:
Practice Address - Street 1:350 ELK AVE
Practice Address - Street 2:
Practice Address - City:GRAND MARSH
Practice Address - State:WI
Practice Address - Zip Code:53936
Practice Address - Country:US
Practice Address - Phone:608-584-6216
Practice Address - Fax:608-584-6226
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist