Provider Demographics
NPI:1710231204
Name:MARTY, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:MARTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1610
Mailing Address - Country:US
Mailing Address - Phone:920-648-3455
Mailing Address - Fax:920-648-2712
Practice Address - Street 1:203 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1610
Practice Address - Country:US
Practice Address - Phone:920-648-3455
Practice Address - Fax:920-648-2712
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11761-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist