Provider Demographics
NPI:1679859987
Name:LUSTEK, MARILYN C (RPH)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:C
Last Name:LUSTEK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 S HASTINGS WAY
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4504
Mailing Address - Country:US
Mailing Address - Phone:715-834-3121
Mailing Address - Fax:715-834-0720
Practice Address - Street 1:1819 S HASTINGS WAY
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4504
Practice Address - Country:US
Practice Address - Phone:715-834-3121
Practice Address - Fax:715-834-0720
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11548-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist