Provider Demographics
NPI:1780954289
Name:SCHULTZ, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SCHULTZ
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 1:250 CENTURY DR
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-7710
Mailing Address - Country:US
Mailing Address - Phone:706-669-8251
Mailing Address - Fax:920-787-5382
Practice Address - Street 1:N2934 HWY 22 N
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982
Practice Address - Country:US
Practice Address - Phone:920-787-5757
Practice Address - Fax:920-787-5382
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-31
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10723-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist