MEDICARE: CORY WEGEHAUPT I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	6296	SD

General Provider Information

NPI Number	:	1518341213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORY WEGEHAUPT I

Provider Business Mailing Address
First Line	:	1507 N MAIN ST
Second Line	:
City	:	MITCHELL
State	:	SD
Zip	:	57301-1017
Country	:	US
Telephone Number	:	605-292-1013
Fax Number	:

Provider Business Practice Location Address
First Line	:	1507 N MAIN ST
Second Line	:
City	:	MITCHELL
State	:	SD
Zip	:	57301-1017
Country	:	US
Telephone Number	:	605-292-1013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	07/13/2015

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Directions to “ CORY WEGEHAUPT I ” Practice Location

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