Provider Demographics
NPI:1922694983
Name:LOBERGER, JACOB (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LOBERGER
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 1:630 N VEL R PHILLIPS AVE UNIT 709
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2809
Mailing Address - Country:US
Mailing Address - Phone:414-520-0442
Mailing Address - Fax:
Practice Address - Street 1:1441 N MAYFAIR RD STE 202
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3281
Practice Address - Country:US
Practice Address - Phone:414-433-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19282-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist