Provider Demographics
NPI:1073898193
Name:LUSARDI, JO ELLEN (RPH)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:ELLEN
Last Name:LUSARDI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:JO
Other - Middle Name:ELLEN
Other - Last Name:SMILTNECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 E MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3330
Mailing Address - Country:US
Mailing Address - Phone:920-435-7679
Mailing Address - Fax:920-435-0591
Practice Address - Street 1:1401 E MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3330
Practice Address - Country:US
Practice Address - Phone:920-435-7679
Practice Address - Fax:920-435-0591
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12476-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302027002OtherREGISTERED PHARMACIST
WI12476-040OtherREGISTERED PHARMACIST