Provider Demographics
NPI:1245080860
Name:PROVIDENCE PHARMACY & WELLNESS
Entity type:Organization
Organization Name:PROVIDENCE PHARMACY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSTIAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:AKPOR-MENSAH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:414-305-7131
Mailing Address - Street 1:1613 E MENLO BLVD
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2249
Mailing Address - Country:US
Mailing Address - Phone:610-841-6265
Mailing Address - Fax:
Practice Address - Street 1:2500 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4218
Practice Address - Country:US
Practice Address - Phone:414-400-0104
Practice Address - Fax:414-400-0107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy