Provider Demographics
NPI:1346524048
Name:HUSTAD, WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:HUSTAD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10320 W SAINT MARTINS RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-2420
Mailing Address - Country:US
Mailing Address - Phone:414-202-1760
Mailing Address - Fax:414-762-9720
Practice Address - Street 1:6241 S PACKARD AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-3031
Practice Address - Country:US
Practice Address - Phone:414-762-9717
Practice Address - Fax:414-762-9720
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8817-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33149300Medicaid