Provider Demographics
NPI:1457892150
Name:XAYPHARATH, JOE
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:XAYPHARATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 W RYAN RD
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-4325
Mailing Address - Country:US
Mailing Address - Phone:414-761-1692
Mailing Address - Fax:
Practice Address - Street 1:2320 W RYAN RD
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-4325
Practice Address - Country:US
Practice Address - Phone:414-761-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17749-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI17749-40OtherPHARMACIST LICENSE