Provider Demographics
NPI:1417262791
Name:WIBLE, MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WIBLE
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 1:1260 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2054
Mailing Address - Country:US
Mailing Address - Phone:985-641-5557
Mailing Address - Fax:985-646-0646
Practice Address - Street 1:1260 FRONT ST
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2054
Practice Address - Country:US
Practice Address - Phone:985-641-5557
Practice Address - Fax:985-646-0646
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist