Provider Demographics
NPI:1871846857
Name:PALM, ANN ELIZABETH (BA, RPH)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:ELIZABETH
Last Name:PALM
Suffix:
Gender:F
Credentials:BA, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-1632
Mailing Address - Country:US
Mailing Address - Phone:920-674-5733
Mailing Address - Fax:920-674-1444
Practice Address - Street 1:132 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-1632
Practice Address - Country:US
Practice Address - Phone:920-674-5733
Practice Address - Fax:920-674-1444
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11669-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist