Provider Demographics
NPI:1568240182
Name:WEISTER, LACY JO (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LACY
Middle Name:JO
Last Name:WEISTER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2607
Mailing Address - Country:US
Mailing Address - Phone:608-343-2808
Mailing Address - Fax:
Practice Address - Street 1:423 MERTON AVE
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-1506
Practice Address - Country:US
Practice Address - Phone:262-367-4751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22395-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist