Provider Demographics
NPI:1295842482
Name:WIEGERT, LAURA M (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:M
Last Name:WIEGERT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6479 WIEGERT RD
Mailing Address - Street 2:
Mailing Address - City:PECATONICA
Mailing Address - State:IL
Mailing Address - Zip Code:61063
Mailing Address - Country:US
Mailing Address - Phone:815-239-1830
Mailing Address - Fax:
Practice Address - Street 1:413 MAIN ST
Practice Address - Street 2:
Practice Address - City:PECATONICA
Practice Address - State:IL
Practice Address - Zip Code:61063-0550
Practice Address - Country:US
Practice Address - Phone:815-239-1200
Practice Address - Fax:815-239-1011
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist