Provider Demographics
NPI:1154694610
Name:RIVEDAL, DAG (RPH)
Entity type:Individual
Prefix:
First Name:DAG
Middle Name:
Last Name:RIVEDAL
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 1:8509 W CASCADE OAKS CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 E LAYTON AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-1402
Practice Address - Country:US
Practice Address - Phone:414-481-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11769401835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist