Provider Demographics
NPI:1710735501
Name:FANSHAW, MARY (PHARMD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:FANSHAW
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N7976 N CRYSTAL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-9383
Mailing Address - Country:US
Mailing Address - Phone:920-382-2269
Mailing Address - Fax:
Practice Address - Street 1:607 PARK AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2201
Practice Address - Country:US
Practice Address - Phone:920-356-0148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21537-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist