Provider Demographics
NPI:1396147625
Name:BORST, LOUISE A (RPH CGP)
Entity type:Individual
Prefix:MRS
First Name:LOUISE
Middle Name:A
Last Name:BORST
Suffix:
Gender:F
Credentials:RPH CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12039 231ST AVE
Mailing Address - Street 2:
Mailing Address - City:TREVOR
Mailing Address - State:WI
Mailing Address - Zip Code:53179-9439
Mailing Address - Country:US
Mailing Address - Phone:262-862-2998
Mailing Address - Fax:
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7884
Practice Address - Country:US
Practice Address - Phone:262-948-5680
Practice Address - Fax:262-948-5681
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12571-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist