Provider Demographics
NPI:1215352190
Name:SIERRALTA, ORLANDO
Entity type:Individual
Prefix:
First Name:ORLANDO
Middle Name:
Last Name:SIERRALTA
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 1:2585 LINEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7122
Mailing Address - Country:US
Mailing Address - Phone:920-662-9450
Mailing Address - Fax:920-662-1912
Practice Address - Street 1:2585 LINEVILLE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-7122
Practice Address - Country:US
Practice Address - Phone:920-662-9450
Practice Address - Fax:920-662-1912
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12254-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist