Provider Demographics
NPI:1972915148
Name:BREITENSTEIN, GEORGE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:BREITENSTEIN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:GEORGE
Other - Middle Name:
Other - Last Name:BREITENSTEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:4131 LOVERS LN
Mailing Address - Street 2:PO BOX 328
Mailing Address - City:AMHERST
Mailing Address - State:WI
Mailing Address - Zip Code:54406-8935
Mailing Address - Country:US
Mailing Address - Phone:715-824-7630
Mailing Address - Fax:
Practice Address - Street 1:115 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-2201
Practice Address - Country:US
Practice Address - Phone:715-256-0400
Practice Address - Fax:715-256-0402
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7640040-40183500000X
FLPS11868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7640040-40OtherPHARMACY LICENSE NO