Provider Demographics
NPI:1376933986
Name:RAFALOW, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:RAFALOW
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 1:100 E MAIN ST UNIT 328
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-5071
Mailing Address - Country:US
Mailing Address - Phone:262-424-9943
Mailing Address - Fax:
Practice Address - Street 1:100 E MAIN ST UNIT 328
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-5071
Practice Address - Country:US
Practice Address - Phone:262-424-9943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16615-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist