Provider Demographics
NPI:1962001339
Name:SWANSON, KATIE ROSE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ROSE
Last Name:SWANSON
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 1:65301 PEARCE RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-4519
Mailing Address - Country:US
Mailing Address - Phone:715-685-8102
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:2020-10-18
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17064183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist