Provider Demographics
NPI:1114390887
Name:MOE, SETH (PHARM D)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:MOE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 SUPERIOR ST
Mailing Address - Street 2:PO BOX 437
Mailing Address - City:THREE LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:54562-9046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1790 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:THREE LAKES
Practice Address - State:WI
Practice Address - Zip Code:54562-9046
Practice Address - Country:US
Practice Address - Phone:715-546-3266
Practice Address - Fax:715-546-2912
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73797183500000X
WI18272-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist