Provider Demographics
NPI:1093051856
Name:WISNOWSKI, ANDREW (PHARMD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WISNOWSKI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 N 3RD CT
Mailing Address - Street 2:
Mailing Address - City:SILVER LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53170-1433
Mailing Address - Country:US
Mailing Address - Phone:262-470-7140
Mailing Address - Fax:
Practice Address - Street 1:351 N EDWARDS BLVD
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4563
Practice Address - Country:US
Practice Address - Phone:262-248-7885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16310-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist