Basic Information
| Provider Information | |||||||||
| NPI: | 1124364112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WETMORE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | PHARM. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9054 BELVEDERE DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553473428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529492098 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2525 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554044518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128136000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2012 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 115707 | MN | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 5302023815 | MI | N | Pharmacy Service Providers | Pharmacist |
No ID Information.