Provider Demographics
NPI:1104371707
Name:WIEGAND, DARLENE (RPH-PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:RPH-PHARMACIST
Other - Prefix:MRS
Other - First Name:DARLENE
Other - Middle Name:
Other - Last Name:WIEGAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:PO BOX 1450
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-1450
Mailing Address - Country:US
Mailing Address - Phone:920-320-2274
Mailing Address - Fax:920-320-5103
Practice Address - Street 1:2300 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-3712
Practice Address - Country:US
Practice Address - Phone:920-320-2274
Practice Address - Fax:920-320-5103
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16674-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33112700Medicaid