Provider Demographics
NPI:1568730109
Name:STREAM, MARY ANNE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:STREAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 SPRINGBROOK S
Mailing Address - Street 2:SOUTH
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2677 S 108TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1925
Practice Address - Country:US
Practice Address - Phone:414-545-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-11
Last Update Date:2011-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15159-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist