Provider Demographics
NPI:1184037533
Name:SY, WIGBERT
Entity Type:Individual
Prefix:
First Name:WIGBERT
Middle Name:
Last Name:SY
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 1:2220 TERRACE VIEW CT
Mailing Address - Street 2:
Mailing Address - City:COOL
Mailing Address - State:CA
Mailing Address - Zip Code:95614-9454
Mailing Address - Country:US
Mailing Address - Phone:530-863-3822
Mailing Address - Fax:
Practice Address - Street 1:2220 TERRACE VIEW CT
Practice Address - Street 2:
Practice Address - City:COOL
Practice Address - State:CA
Practice Address - Zip Code:95614-9454
Practice Address - Country:US
Practice Address - Phone:530-863-3822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH44293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist