Provider Demographics
NPI:1053697136
Name:SWANSON, JOHN CHARLES (BS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:SWANSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 N JOHNS ST
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-1277
Mailing Address - Country:US
Mailing Address - Phone:608-935-2041
Mailing Address - Fax:608-935-5737
Practice Address - Street 1:1133 N JOHNS ST
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-1277
Practice Address - Country:US
Practice Address - Phone:608-935-2041
Practice Address - Fax:608-935-5737
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI778940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist