Provider Demographics
NPI:1922618776
Name:PROBASCO, ROBERT (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PROBASCO
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 1:115 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-2201
Mailing Address - Country:US
Mailing Address - Phone:715-256-0400
Mailing Address - Fax:
Practice Address - Street 1:115 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-2201
Practice Address - Country:US
Practice Address - Phone:715-256-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10317-401835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care