Provider Demographics
NPI:1073898060
Name:TESTER, RODNEYT
Entity Type:Individual
Prefix:
First Name:RODNEYT
Middle Name:
Last Name:TESTER
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 1:2015 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2538
Mailing Address - Country:US
Mailing Address - Phone:715-392-9550
Mailing Address - Fax:715-392-3724
Practice Address - Street 1:2015 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2538
Practice Address - Country:US
Practice Address - Phone:715-392-9550
Practice Address - Fax:715-392-3724
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13567-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist