Provider Demographics
NPI:1023166394
Name:L & P NYBERG LLC
Entity type:Organization
Organization Name:L & P NYBERG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:NYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-380-9061
Mailing Address - Street 1:520 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:WI
Mailing Address - Zip Code:54736-1065
Mailing Address - Country:US
Mailing Address - Phone:715-672-5900
Mailing Address - Fax:715-672-5908
Practice Address - Street 1:520 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DURAND
Practice Address - State:WI
Practice Address - Zip Code:54736-1065
Practice Address - Country:US
Practice Address - Phone:715-672-5900
Practice Address - Fax:715-672-5908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6151333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5114905OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33018900Medicaid
WI0253380003Medicare NSC