Provider Demographics
NPI:1770805111
Name:HERBST, STEPHEN DOUGLAS (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DOUGLAS
Last Name:HERBST
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N ROCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-1142
Mailing Address - Country:US
Mailing Address - Phone:262-363-4001
Mailing Address - Fax:262-363-5699
Practice Address - Street 1:801 N ROCHESTER ST
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1142
Practice Address - Country:US
Practice Address - Phone:262-363-4001
Practice Address - Fax:262-363-5699
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13448-040183500000X
AZS013150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist