Provider Demographics
NPI:1538413927
Name:ENGLEBERT, COLLEEN (RPH)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:ENGLEBERT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 BROWN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2491
Mailing Address - Country:US
Mailing Address - Phone:262-567-6651
Mailing Address - Fax:262-567-5028
Practice Address - Street 1:1260 BROWN ST
Practice Address - Street 2:SUITE A
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-2491
Practice Address - Country:US
Practice Address - Phone:262-567-6651
Practice Address - Fax:262-567-5028
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11728183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist