Provider Demographics
NPI:1396528659
Name:HUENINK, MARISSA LEE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEE
Last Name:HUENINK
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:53919-0009
Mailing Address - Country:US
Mailing Address - Phone:920-418-5573
Mailing Address - Fax:
Practice Address - Street 1:20 W PIONEER RD
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6152
Practice Address - Country:US
Practice Address - Phone:920-907-0556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22306-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist