Provider Demographics
NPI:1689906901
Name:SMITH, JUSTINE JUDY (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:JUDY
Last Name:SMITH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:
Other - Last Name:STRAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1211 EAST GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2207
Mailing Address - Country:US
Mailing Address - Phone:715-526-6551
Mailing Address - Fax:
Practice Address - Street 1:1211 E GREEN BAY ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2207
Practice Address - Country:US
Practice Address - Phone:715-526-6551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13761040183500000X
IL051030602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist