Provider Demographics
NPI:1215463005
Name:KAGERBAUER, LORI LEA (RPH)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:LEA
Last Name:KAGERBAUER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2357
Mailing Address - Country:US
Mailing Address - Phone:715-524-2011
Mailing Address - Fax:
Practice Address - Street 1:117 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2357
Practice Address - Country:US
Practice Address - Phone:715-524-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist