Provider Demographics
NPI:1376824300
Name:AUGUSTINE, ROBERT MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:AUGUSTINE
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:N9850 STATE ROAD 22
Mailing Address - Street 2:
Mailing Address - City:PARDEEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53954-9753
Mailing Address - Country:US
Mailing Address - Phone:608-429-9348
Mailing Address - Fax:
Practice Address - Street 1:807 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DE FOREST
Practice Address - State:WI
Practice Address - Zip Code:53532-1480
Practice Address - Country:US
Practice Address - Phone:608-846-3674
Practice Address - Fax:608-846-3684
Is Sole Proprietor?:No
Enumeration Date:2011-09-04
Last Update Date:2011-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist