Healthcare Provider Details

I. General information

NPI: 1295842482
Provider Name (Legal Business Name): LAURA M WIEGERT RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 MAIN ST
PECATONICA IL
61063-0550
US

IV. Provider business mailing address

6479 WIEGERT RD
PECATONICA IL
61063
US

V. Phone/Fax

Practice location:
  • Phone: 815-239-1200
  • Fax: 815-239-1011
Mailing address:
  • Phone: 815-239-1830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: