Provider Demographics
NPI:1124395124
Name:BOUZEK, MICHAEL D (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:BOUZEK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38279 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-8419
Mailing Address - Country:US
Mailing Address - Phone:608-326-4531
Mailing Address - Fax:
Practice Address - Street 1:109 N MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-1512
Practice Address - Country:US
Practice Address - Phone:608-326-0581
Practice Address - Fax:608-326-0586
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9071-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist