Provider Demographics
NPI:1851999320
Name:MASSOPUST, DONALD BRADLEY
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:BRADLEY
Last Name:MASSOPUST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 E ARCH ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-2003
Mailing Address - Country:US
Mailing Address - Phone:906-364-2771
Mailing Address - Fax:
Practice Address - Street 1:2500 LAKE SHORE DR E
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-2421
Practice Address - Country:US
Practice Address - Phone:715-682-3660
Practice Address - Fax:715-685-9941
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10793183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist