Provider Demographics
NPI:1659979367
Name:WIATR, CHARLES
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:WIATR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 CREST VIEW DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-9487
Mailing Address - Country:US
Mailing Address - Phone:715-386-1345
Mailing Address - Fax:
Practice Address - Street 1:2222 CREST VIEW DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9487
Practice Address - Country:US
Practice Address - Phone:715-386-1345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1213740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist