Provider Demographics
NPI:1598044000
Name:WALLENBERG, BRADFORD GEORGE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:GEORGE
Last Name:WALLENBERG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-3816
Mailing Address - Country:US
Mailing Address - Phone:605-357-9359
Mailing Address - Fax:605-357-9496
Practice Address - Street 1:2605 W 12TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-3816
Practice Address - Country:US
Practice Address - Phone:605-357-9359
Practice Address - Fax:605-357-9496
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist