Provider Demographics
NPI:1770570210
Name:WIBERG, CODY (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:CODY
Middle Name:
Last Name:WIBERG
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2437
Mailing Address - Country:US
Mailing Address - Phone:651-388-3102
Mailing Address - Fax:612-617-2212
Practice Address - Street 1:2829 UNIVERSITY AVE SE
Practice Address - Street 2:SUITE 530
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3250
Practice Address - Country:US
Practice Address - Phone:612-617-2201
Practice Address - Fax:612-617-2212
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114077-8183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist