Provider Demographics
NPI:1760099618
Name:HOUSTON, MARY JO (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:HOUSTON
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 1:710 MAJESTIC VIEW LN
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-6508
Mailing Address - Country:US
Mailing Address - Phone:262-308-5498
Mailing Address - Fax:
Practice Address - Street 1:1021 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4499
Practice Address - Country:US
Practice Address - Phone:262-567-9173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist