Provider Demographics
NPI:1295334613
Name:LYBERG, TAMMY (PHARMD)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:LYBERG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 FOLKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7473
Mailing Address - Country:US
Mailing Address - Phone:616-617-4592
Mailing Address - Fax:
Practice Address - Street 1:2440 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4711
Practice Address - Country:US
Practice Address - Phone:920-499-2330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17402-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist