Provider Demographics
NPI:1205549425
Name:LILLEBERG, BENJAMIN MATTHEW
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MATTHEW
Last Name:LILLEBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 SHORT ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-6221
Mailing Address - Country:US
Mailing Address - Phone:763-447-7276
Mailing Address - Fax:
Practice Address - Street 1:250 RICHMOND WAY
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-6829
Practice Address - Country:US
Practice Address - Phone:715-246-9097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21489-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist