Provider Demographics
NPI:1063682508
Name:WOOD, TARA LEE (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:LEE
Last Name:WOOD
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1642
Mailing Address - Country:US
Mailing Address - Phone:608-375-6307
Mailing Address - Fax:608-375-6198
Practice Address - Street 1:205 PARKER ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1642
Practice Address - Country:US
Practice Address - Phone:608-375-6307
Practice Address - Fax:608-375-6198
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13988183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33051200Medicaid