=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770570210
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CODY WIBERG PHARM.D., R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2829 UNIVERSITY AVE SE SUITE 530
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55414-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-617-2201
-----------------------------------------------------
Fax | 612-617-2212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 COLLEGE AVE
-----------------------------------------------------
City | RED WING
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55066-2437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-388-3102
-----------------------------------------------------
Fax | 612-617-2212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 114077-8
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------