Provider Demographics
NPI:1669080784
Name:BOLD, SPENCER (PHARMD)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:BOLD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11509 N LAGUNA DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3119
Mailing Address - Country:US
Mailing Address - Phone:414-243-9579
Mailing Address - Fax:
Practice Address - Street 1:N65W24838 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-2670
Practice Address - Country:US
Practice Address - Phone:262-946-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20357-40183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist