Provider Demographics
NPI:1164618013
Name:RYSTICKEN, MARK ALAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:RYSTICKEN
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 1:1010 W RYAN ST
Mailing Address - Street 2:
Mailing Address - City:BRILLION
Mailing Address - State:WI
Mailing Address - Zip Code:54110-1079
Mailing Address - Country:US
Mailing Address - Phone:920-756-2640
Mailing Address - Fax:920-756-9262
Practice Address - Street 1:1010 W RYAN ST
Practice Address - Street 2:
Practice Address - City:BRILLION
Practice Address - State:WI
Practice Address - Zip Code:54110-1079
Practice Address - Country:US
Practice Address - Phone:920-756-2640
Practice Address - Fax:920-756-9262
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist