Provider Demographics
NPI:1609400852
Name:SPROSTY, MACI
Entity Type:Individual
Prefix:
First Name:MACI
Middle Name:
Last Name:SPROSTY
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 1:50096 STATE HIGHWAY 171
Mailing Address - Street 2:
Mailing Address - City:GAYS MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:54631-7114
Mailing Address - Country:US
Mailing Address - Phone:608-606-4028
Mailing Address - Fax:
Practice Address - Street 1:900 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4729
Practice Address - Country:US
Practice Address - Phone:608-796-2058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20031-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist