Provider Demographics
NPI:1073147617
Name:SIVERTSEN, ZARA (RPH)
Entity Type:Individual
Prefix:
First Name:ZARA
Middle Name:
Last Name:SIVERTSEN
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 1:502 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-2576
Mailing Address - Country:US
Mailing Address - Phone:715-736-0120
Mailing Address - Fax:
Practice Address - Street 1:502 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-2576
Practice Address - Country:US
Practice Address - Phone:715-736-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-22
Last Update Date:2020-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19480-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist