Provider Demographics
NPI:1679108211
Name:FORD, PAUL
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:FORD
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 1:2607 N DOWNER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4245
Mailing Address - Country:US
Mailing Address - Phone:414-906-0942
Mailing Address - Fax:414-906-1158
Practice Address - Street 1:2607 N DOWNER AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4245
Practice Address - Country:US
Practice Address - Phone:414-906-0942
Practice Address - Fax:414-906-1158
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13141-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist