Provider Demographics
NPI:1134406671
Name:BRENNAN, MARY JO
Entity type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:
Last Name:BRENNAN
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 1:1021 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4457
Mailing Address - Country:US
Mailing Address - Phone:262-567-9173
Mailing Address - Fax:262-567-3034
Practice Address - Street 1:1021 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4457
Practice Address - Country:US
Practice Address - Phone:262-567-9173
Practice Address - Fax:262-567-3034
Is Sole Proprietor?:No
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI08261-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI08261-040OtherLICENSE NUMBER