Provider Demographics
NPI:1295409563
Name:RIETH, JONATHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:RIETH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E OGDEN AVE APT 318
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-2939
Mailing Address - Country:US
Mailing Address - Phone:719-459-9156
Mailing Address - Fax:
Practice Address - Street 1:1110 E OGDEN AVE APT 318
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-2939
Practice Address - Country:US
Practice Address - Phone:719-459-9156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2092440183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2092440Medicaid
WI2092440OtherINSURANCE