Provider Demographics
NPI:1003414822
Name:GREMBAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GREMBAN
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 1:106 WOODLARK CT
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1257
Mailing Address - Country:US
Mailing Address - Phone:920-265-4571
Mailing Address - Fax:
Practice Address - Street 1:4140 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-1334
Practice Address - Country:US
Practice Address - Phone:414-978-2007
Practice Address - Fax:414-978-2008
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17947-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist