Provider Demographics
NPI:1720410434
Name:NALBACH, JACKIE (RPH)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:NALBACH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2928 E RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-9001
Mailing Address - Country:US
Mailing Address - Phone:920-558-3363
Mailing Address - Fax:
Practice Address - Street 1:699 S GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-3153
Practice Address - Country:US
Practice Address - Phone:920-751-0270
Practice Address - Fax:920-751-0267
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11945 40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist