Provider Demographics
NPI:1336613082
Name:HAVICAN, CARTER
Entity type:Individual
Prefix:
First Name:CARTER
Middle Name:
Last Name:HAVICAN
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 1:1405 MILL ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2155
Mailing Address - Country:US
Mailing Address - Phone:920-531-2400
Mailing Address - Fax:
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-531-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI19633OtherLICENSE