Provider Demographics
NPI:1043845225
Name:SMITH, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 RUSTIC WOODS CT
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2690
Mailing Address - Country:US
Mailing Address - Phone:414-339-8542
Mailing Address - Fax:
Practice Address - Street 1:6705 S 27TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9430
Practice Address - Country:US
Practice Address - Phone:414-304-1255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-08
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18458-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist