Provider Demographics
NPI:1639777089
Name:HUSAIN, JEREMY HAFIZ I (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:HAFIZ
Last Name:HUSAIN
Suffix:I
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 N DURKEE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3711
Mailing Address - Country:US
Mailing Address - Phone:608-921-4265
Mailing Address - Fax:
Practice Address - Street 1:955 N MUTUAL WAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8415
Practice Address - Country:US
Practice Address - Phone:920-954-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17936-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist