Provider Demographics
NPI:1043970304
Name:STUBENVOLL, MICHAEL DAVID (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:STUBENVOLL
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 1:10578 COUNTRY WALK DR UNIT 27
Mailing Address - Street 2:
Mailing Address - City:SISTER BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54234-9114
Mailing Address - Country:US
Mailing Address - Phone:920-633-4060
Mailing Address - Fax:920-633-4062
Practice Address - Street 1:10578 COUNTRY WALK DR UNIT 27
Practice Address - Street 2:
Practice Address - City:SISTER BAY
Practice Address - State:WI
Practice Address - Zip Code:54234-9114
Practice Address - Country:US
Practice Address - Phone:920-633-4060
Practice Address - Fax:920-633-4062
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21220-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist