Provider Demographics
NPI:1083268171
Name:CARLSON, JAMIN DIEHL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JAMIN
Middle Name:DIEHL
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 PHILLIPS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAUK CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53583-1526
Mailing Address - Country:US
Mailing Address - Phone:608-643-5182
Mailing Address - Fax:608-643-5209
Practice Address - Street 1:333 PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:SAUK CITY
Practice Address - State:WI
Practice Address - Zip Code:53583-1526
Practice Address - Country:US
Practice Address - Phone:608-643-5182
Practice Address - Fax:608-643-5209
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-28
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19420-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist