Provider Demographics
NPI:1689720518
Name:HALBERG, JOHN AVERY (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:AVERY
Last Name:HALBERG
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 1:704 CLAYTON STREET
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WI
Mailing Address - Zip Code:54822-9429
Mailing Address - Country:US
Mailing Address - Phone:715-642-1543
Mailing Address - Fax:
Practice Address - Street 1:JAMES PHARMACY 215 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:TURTLE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54889
Practice Address - Country:US
Practice Address - Phone:715-986-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10099040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist