Provider Demographics
NPI:1649520008
Name:ATHLETE PHARMACIST LLC
Entity type:Organization
Organization Name:ATHLETE PHARMACIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:V
Authorized Official - Last Name:LORSON
Authorized Official - Suffix:II
Authorized Official - Credentials:PHARMD, CGP
Authorized Official - Phone:414-207-0309
Mailing Address - Street 1:211 NAUTILUS DR APT 8
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4358
Mailing Address - Country:US
Mailing Address - Phone:414-207-0309
Mailing Address - Fax:
Practice Address - Street 1:211 NAUTILUS DR APT 8
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4358
Practice Address - Country:US
Practice Address - Phone:414-207-0309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local