Provider Demographics
NPI:1972102739
Name:MODI, PRAKRUTI
Entity Type:Individual
Prefix:
First Name:PRAKRUTI
Middle Name:
Last Name:MODI
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 1:6701 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9430
Mailing Address - Country:US
Mailing Address - Phone:414-761-9571
Mailing Address - Fax:414-761-3106
Practice Address - Street 1:6701 S 27TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9430
Practice Address - Country:US
Practice Address - Phone:414-761-9571
Practice Address - Fax:414-761-3106
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17683-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist