Provider Demographics
NPI:1508855867
Name:WENNERSTRAND, ROBERT WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:WENNERSTRAND
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 1:12698 MOUNTAIN ASH DR
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8387
Mailing Address - Country:US
Mailing Address - Phone:218-825-7564
Mailing Address - Fax:
Practice Address - Street 1:108 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3575
Practice Address - Country:US
Practice Address - Phone:218-829-0347
Practice Address - Fax:218-829-4701
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1157062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist