Provider Demographics
NPI:1780218420
Name:PAVLIK, BROCK JORDAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:JORDAN
Last Name:PAVLIK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-1004
Mailing Address - Country:US
Mailing Address - Phone:608-835-6771
Mailing Address - Fax:608-835-0079
Practice Address - Street 1:704 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-1004
Practice Address - Country:US
Practice Address - Phone:608-835-6771
Practice Address - Fax:608-835-0079
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20085-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist