Provider Demographics
NPI:1417133984
Name:FOSS, ERIC (RPH)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:FOSS
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:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-0645
Mailing Address - Country:US
Mailing Address - Phone:920-787-5757
Mailing Address - Fax:920-787-5382
Practice Address - Street 1:N2934 STATE ROAD 22
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-5267
Practice Address - Country:US
Practice Address - Phone:920-787-5757
Practice Address - Fax:920-787-5382
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11391-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist