Provider Demographics
NPI:1851782353
Name:BRAUER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRAUER
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 1:701 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-6213
Mailing Address - Country:US
Mailing Address - Phone:920-261-1920
Mailing Address - Fax:920-261-7010
Practice Address - Street 1:701 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-6213
Practice Address - Country:US
Practice Address - Phone:920-261-1920
Practice Address - Fax:920-261-7010
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11614-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist