Provider Demographics
NPI:1013403641
Name:SIEBERG, CHARLES (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SIEBERG
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 1:281 BUTTERWORTH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-1120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1217 8TH ST N
Practice Address - Street 2:
Practice Address - City:NEW ULM
Practice Address - State:MN
Practice Address - Zip Code:56073-1552
Practice Address - Country:US
Practice Address - Phone:507-217-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist