Provider Demographics
NPI:1023122561
Name:NYBERG, BLAIN E (RPH)
Entity type:Individual
Prefix:MR
First Name:BLAIN
Middle Name:E
Last Name:NYBERG
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 1:9601 TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-9099
Mailing Address - Country:US
Mailing Address - Phone:715-358-1217
Mailing Address - Fax:715-358-1183
Practice Address - Street 1:9601 TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-9099
Practice Address - Country:US
Practice Address - Phone:715-358-1217
Practice Address - Fax:715-358-1183
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9584-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist