Provider Demographics
NPI:1285902429
Name:PISTINER, MARY B (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:PISTINER
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 1:518 W KENILWORTH CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092
Mailing Address - Country:US
Mailing Address - Phone:262-241-8243
Mailing Address - Fax:
Practice Address - Street 1:W62 N190 WASHINGTON AVE
Practice Address - Street 2:WALGREENS
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012
Practice Address - Country:US
Practice Address - Phone:262-375-3039
Practice Address - Fax:262-375-2368
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9760-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist