MEDICARE: DR. CODY WIBERG PHARM.D., R.PH.

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	114077-8	MN

General Provider Information

NPI Number	:	1770570210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CODY WIBERG PHARM.D., R.PH.

Provider Business Mailing Address
First Line	:	1011 COLLEGE AVE
Second Line	:
City	:	RED WING
State	:	MN
Zip	:	55066-2437
Country	:	US
Telephone Number	:	651-388-3102
Fax Number	:	612-617-2212

Provider Business Practice Location Address
First Line	:	2829 UNIVERSITY AVE SE
Second Line	:	SUITE 530
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-3250
Country	:	US
Telephone Number	:	612-617-2201
Fax Number	:	612-617-2212

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	07/08/2007

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