Provider Demographics
NPI:1699373258
Name:LUSIS, GINA LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:LYNN
Last Name:LUSIS
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 1:10309 N STANFORD DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097-3632
Mailing Address - Country:US
Mailing Address - Phone:262-844-8773
Mailing Address - Fax:
Practice Address - Street 1:825 E GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080-2618
Practice Address - Country:US
Practice Address - Phone:262-284-9881
Practice Address - Fax:262-284-1174
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12062-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist