Provider Demographics
NPI:1730465345
Name:NIEBAUM, BENJAMIN ISAAC (PHARMD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ISAAC
Last Name:NIEBAUM
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 1:2402 RIDGEVIEW DR
Mailing Address - Street 2:APT. 302
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7853
Mailing Address - Country:US
Mailing Address - Phone:763-242-3476
Mailing Address - Fax:
Practice Address - Street 1:1106 W CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6124
Practice Address - Country:US
Practice Address - Phone:715-852-0063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15998-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist