Provider Demographics
NPI:1255421608
Name:MAYER, DMITRI (RPH)
Entity type:Individual
Prefix:
First Name:DMITRI
Middle Name:
Last Name:MAYER
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 1:2851 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5855
Mailing Address - Country:US
Mailing Address - Phone:920-431-2584
Mailing Address - Fax:414-389-4216
Practice Address - Street 1:2851 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5855
Practice Address - Country:US
Practice Address - Phone:920-431-2584
Practice Address - Fax:414-389-4216
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13720183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist