Provider Demographics
NPI:1558653683
Name:WILBERG, MARK T (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:WILBERG
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 1:8202 EXCELSIOR DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1906
Mailing Address - Country:US
Mailing Address - Phone:608-441-3289
Mailing Address - Fax:608-662-5095
Practice Address - Street 1:8202 EXCELSIOR DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1906
Practice Address - Country:US
Practice Address - Phone:608-441-3289
Practice Address - Fax:608-662-5095
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist