Provider Demographics
NPI:1194079921
Name:REISWIG, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:REISWIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 UPPER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-1165
Mailing Address - Country:US
Mailing Address - Phone:605-645-3188
Mailing Address - Fax:
Practice Address - Street 1:280 UPPER VALLEY RD
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1165
Practice Address - Country:US
Practice Address - Phone:605-645-3188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist