Provider Demographics
NPI:1053860908
Name:MILLER, MARIS (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARIS
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MARIS
Other - Middle Name:
Other - Last Name:SCHAEFER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:PHARMACY PLUS
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8585
Mailing Address - Fax:920-926-8935
Practice Address - Street 1:420 E DIVISION ST
Practice Address - Street 2:PHARMACY PLUS
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8585
Practice Address - Fax:920-926-8935
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17718-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI17718-40OtherWISCONSIN PHARMACIST LICENSE NUMBER