Provider Demographics
NPI:1407109630
Name:RATHKE, RYAN LEE (RPH)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:LEE
Last Name:RATHKE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 REED AVE
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2026
Mailing Address - Country:US
Mailing Address - Phone:920-686-5237
Mailing Address - Fax:
Practice Address - Street 1:601 REED AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2026
Practice Address - Country:US
Practice Address - Phone:920-686-5237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13296-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist