Provider Demographics
NPI:1417233016
Name:WELLNER, GREGG WILLIAM (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGG
Middle Name:WILLIAM
Last Name:WELLNER
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:N2360 SUMMERVILLE PARK RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-9621
Mailing Address - Country:US
Mailing Address - Phone:847-682-9133
Mailing Address - Fax:
Practice Address - Street 1:N2360 SUMMERVILLE PARK RD
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-9621
Practice Address - Country:US
Practice Address - Phone:847-682-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14705-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist