Provider Demographics
NPI:1548865173
Name:WAHLSTROM, TODD (RPH)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:WAHLSTROM
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 1:1008 HIGHWAY 55 E
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-8906
Mailing Address - Country:US
Mailing Address - Phone:763-682-5828
Mailing Address - Fax:763-682-5968
Practice Address - Street 1:1008 HIGHWAY 55 E
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-8906
Practice Address - Country:US
Practice Address - Phone:763-682-5828
Practice Address - Fax:763-682-5968
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist