Provider Demographics
NPI:1750820759
Name:LUBOFF, ADAM EDWARD (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:EDWARD
Last Name:LUBOFF
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3232 N BALLARD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8804
Mailing Address - Country:US
Mailing Address - Phone:920-702-4798
Mailing Address - Fax:
Practice Address - Street 1:3925 N GATEWAY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7863
Practice Address - Country:US
Practice Address - Phone:920-702-4802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17658-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist