Provider Demographics
NPI:1902940141
Name:MOLSTAD, DANIEL BEN (RPH)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:BEN
Last Name:MOLSTAD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15520 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:ETTRICK
Mailing Address - State:WI
Mailing Address - Zip Code:54627-7839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:WI
Practice Address - Zip Code:54616-9367
Practice Address - Country:US
Practice Address - Phone:608-989-2919
Practice Address - Fax:608-989-2837
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9148040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist