Provider Demographics
NPI:1043589856
Name:KALSTROM, WILBUR WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:WILBUR
Middle Name:WAYNE
Last Name:KALSTROM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 16TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-1307
Mailing Address - Country:US
Mailing Address - Phone:320-251-0156
Mailing Address - Fax:
Practice Address - Street 1:1100 2ND ST S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2152
Practice Address - Country:US
Practice Address - Phone:320-654-8542
Practice Address - Fax:320-654-8603
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist