Provider Demographics
NPI:1306271648
Name:BIERSACH, PENNY NICKEL
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:NICKEL
Last Name:BIERSACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5595 COUNTY ROAD Z
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9224
Mailing Address - Country:US
Mailing Address - Phone:262-306-2140
Mailing Address - Fax:262-306-2141
Practice Address - Street 1:5595 COUNTY ROAD Z
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9224
Practice Address - Country:US
Practice Address - Phone:262-306-2140
Practice Address - Fax:262-306-2141
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7798-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7798-40OtherPHARMACIST LICENSE