Provider Demographics
NPI:1780940668
Name:MYNATT, CYNTHIA MARIE (RPH)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:MARIE
Last Name:MYNATT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4618
Mailing Address - Country:US
Mailing Address - Phone:262-567-9525
Mailing Address - Fax:262-567-5293
Practice Address - Street 1:1450 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4618
Practice Address - Country:US
Practice Address - Phone:262-567-9254
Practice Address - Fax:262-567-5293
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11258-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist