Provider Demographics
NPI:1821342627
Name:RIENDEAU, BRUCE JON (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:JON
Last Name:RIENDEAU
Suffix:
Gender:M
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:N2585 PLAZA RD # 1409
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-7706
Mailing Address - Country:US
Mailing Address - Phone:920-787-2090
Mailing Address - Fax:920-787-4605
Practice Address - Street 1:N2585 PLAZA RD # 1409
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-7706
Practice Address - Country:US
Practice Address - Phone:920-787-2090
Practice Address - Fax:920-787-4605
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13298-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1811941586Medicaid