Provider Demographics
NPI:1114527751
Name:POPELKA, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:POPELKA
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 1:1536 EGG HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1257
Mailing Address - Country:US
Mailing Address - Phone:920-746-0412
Mailing Address - Fax:
Practice Address - Street 1:1536 EGG HARBOR RD
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1257
Practice Address - Country:US
Practice Address - Phone:920-746-0412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20037-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist