Provider Demographics
NPI:1407100555
Name:ZIMMERMAN, MARY ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:ZIMMERMAN
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 1:220 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:WI
Mailing Address - Zip Code:53910-9459
Mailing Address - Country:US
Mailing Address - Phone:608-339-3630
Mailing Address - Fax:608-339-9536
Practice Address - Street 1:220 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:ADAMS
Practice Address - State:WI
Practice Address - Zip Code:53910-9459
Practice Address - Country:US
Practice Address - Phone:608-339-3630
Practice Address - Fax:608-339-9536
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-27
Last Update Date:2012-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11486183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1578517710Medicaid