Provider Demographics
NPI:1972835106
Name:EGGERICHS, MARK J (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:EGGERICHS
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 1:1125 SUNDT LN
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1284
Mailing Address - Country:US
Mailing Address - Phone:608-873-0268
Mailing Address - Fax:
Practice Address - Street 1:1450 E GENEVA ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2025
Practice Address - Country:US
Practice Address - Phone:262-728-0062
Practice Address - Fax:262-728-0055
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9135-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist