Provider Demographics
NPI:1083990733
Name:LICHTFUSS, BRYAN (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:LICHTFUSS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 RACINE ST
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-2359
Mailing Address - Country:US
Mailing Address - Phone:920-722-4759
Mailing Address - Fax:920-722-3197
Practice Address - Street 1:305 RACINE ST
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-2359
Practice Address - Country:US
Practice Address - Phone:920-722-4759
Practice Address - Fax:920-722-3197
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14972-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14972-40OtherPHARMACY LICENSE NUMBER