Provider Demographics
NPI:1265785448
Name:BALLWEG, DENNIS JOHN (RPH)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:JOHN
Last Name:BALLWEG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:S9002 WOODFORD LN
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-9773
Mailing Address - Country:US
Mailing Address - Phone:608-643-5108
Mailing Address - Fax:608-643-6533
Practice Address - Street 1:1200 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2041
Practice Address - Country:US
Practice Address - Phone:608-643-6500
Practice Address - Fax:608-643-6533
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11459183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist