Provider Demographics
NPI:1235763582
Name:IKEM, PATRICIA N
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:N
Last Name:IKEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-7629
Mailing Address - Country:US
Mailing Address - Phone:920-206-9588
Mailing Address - Fax:920-206-9702
Practice Address - Street 1:301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-7629
Practice Address - Country:US
Practice Address - Phone:920-206-9588
Practice Address - Fax:920-206-9702
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist