Provider Demographics
NPI:1518341213
Name:WEGEHAUPT, CORY I
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:WEGEHAUPT
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-1017
Mailing Address - Country:US
Mailing Address - Phone:605-292-1013
Mailing Address - Fax:
Practice Address - Street 1:1507 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-1017
Practice Address - Country:US
Practice Address - Phone:605-292-1013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6296183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist