Provider Demographics
NPI:1245508191
Name:PERSTEN, MICHAEL J (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:PERSTEN
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 1:11270 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-0000
Mailing Address - Country:US
Mailing Address - Phone:262-241-5539
Mailing Address - Fax:
Practice Address - Street 1:11270 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-0000
Practice Address - Country:US
Practice Address - Phone:262-241-5539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7909-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist