Provider Demographics
NPI:1316214224
Name:SHOBERG, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:SHOBERG
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 1:1001 SUMMIT AVE N APT 217
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2598
Mailing Address - Country:US
Mailing Address - Phone:320-253-6601
Mailing Address - Fax:
Practice Address - Street 1:115 2ND AVE N
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-1605
Practice Address - Country:US
Practice Address - Phone:320-253-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-20
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115064183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist