Healthcare Provider Details

I. General information

NPI: 1457637738
Provider Name (Legal Business Name): WALLACE L GEHRING RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 8TH ST S
WISCONSIN RAPIDS WI
54494-6563
US

IV. Provider business mailing address

W3396 DUCK CREEK AVE
MONTELLO WI
53949-8431
US

V. Phone/Fax

Practice location:
  • Phone: 715-424-4082
  • Fax:
Mailing address:
  • Phone: 920-293-8787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8450-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: