Provider Demographics
NPI:1972693034
Name:POLICELLO, JOHN J (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:J
Last Name:POLICELLO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 PARMENTER ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:645 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DE FOREST
Practice Address - State:WI
Practice Address - Zip Code:53532-1421
Practice Address - Country:US
Practice Address - Phone:608-846-4736
Practice Address - Fax:608-846-6892
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIR8456183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist