Provider Demographics
NPI:1740888254
Name:FATCHIKOVA, VELISLAVA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:VELISLAVA
Middle Name:
Last Name:FATCHIKOVA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 QUARRY PARK DR APT 1
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-8195
Mailing Address - Country:US
Mailing Address - Phone:715-225-8183
Mailing Address - Fax:
Practice Address - Street 1:4115 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5491
Practice Address - Country:US
Practice Address - Phone:920-684-5016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19976-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist