Provider Demographics
NPI:1174122386
Name:BUTH, LANCE
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:BUTH
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 1:1033 NORFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SUAMICO
Mailing Address - State:WI
Mailing Address - Zip Code:54173-8529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1244 E GREEN BAY ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2208
Practice Address - Country:US
Practice Address - Phone:715-524-5983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14743-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist