Provider Demographics
NPI:1336424217
Name:BADGER, GWEN
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:BADGER
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 1:1601 CHARLESTON CIR
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-2332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2010 BRANCH ST
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3026
Practice Address - Country:US
Practice Address - Phone:608-831-6548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist