Provider Demographics
NPI:1306283734
Name:LICHT, PORTIA W (R PH)
Entity type:Individual
Prefix:
First Name:PORTIA
Middle Name:W
Last Name:LICHT
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 BREMER RD
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-4141
Mailing Address - Country:US
Mailing Address - Phone:319-352-4756
Mailing Address - Fax:
Practice Address - Street 1:920 BREMER RD
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-4141
Practice Address - Country:US
Practice Address - Phone:319-352-4756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA13316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist