Provider Demographics
NPI:1619313533
Name:OPACICH, STEPHAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHAN
Middle Name:
Last Name:OPACICH
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 1:1641 N EUGENE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-2428
Mailing Address - Country:US
Mailing Address - Phone:920-209-2182
Mailing Address - Fax:
Practice Address - Street 1:1000 W NORTHLAND AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1419
Practice Address - Country:US
Practice Address - Phone:920-739-6871
Practice Address - Fax:920-731-6167
Is Sole Proprietor?:No
Enumeration Date:2013-05-18
Last Update Date:2013-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10463-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist