Provider Demographics
NPI:1801343975
Name:LOVE, MITCHEL
Entity type:Individual
Prefix:DR
First Name:MITCHEL
Middle Name:
Last Name:LOVE
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 1:2502 SHOPKO DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4119
Mailing Address - Country:US
Mailing Address - Phone:608-243-7788
Mailing Address - Fax:608-243-7800
Practice Address - Street 1:2502 SHOPKO DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4119
Practice Address - Country:US
Practice Address - Phone:608-243-7788
Practice Address - Fax:608-243-7800
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1828740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist