Provider Demographics
NPI:1164047684
Name:GONINEN, MARISA KAY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:KAY
Last Name:GONINEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:MARISA
Other - Middle Name:KAY
Other - Last Name:FREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:12500 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2600
Mailing Address - Country:US
Mailing Address - Phone:262-957-8239
Mailing Address - Fax:
Practice Address - Street 1:12500 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2600
Practice Address - Country:US
Practice Address - Phone:262-957-8239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0513024311835P2201X
WI18402-401835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care