Provider Demographics
NPI:1508110693
Name:AMMERMAN, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:AMMERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9366 HWY 16
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650
Mailing Address - Country:US
Mailing Address - Phone:608-781-5404
Mailing Address - Fax:
Practice Address - Street 1:9366 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8526
Practice Address - Country:US
Practice Address - Phone:608-781-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5695760017Medicare PIN