Provider Demographics
NPI:1205227600
Name:LE-MASKE, MAI-PHUONG (RPH)
Entity Type:Individual
Prefix:
First Name:MAI-PHUONG
Middle Name:
Last Name:LE-MASKE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 E MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-3929
Mailing Address - Country:US
Mailing Address - Phone:262-896-6767
Mailing Address - Fax:262-896-6794
Practice Address - Street 1:1535 E MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-3929
Practice Address - Country:US
Practice Address - Phone:262-896-6767
Practice Address - Fax:262-896-6794
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-07
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13694-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist