Individual
POV NHEAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2024 85TH AVE N, BROOKLYN PARK, MN 55444-1495
(904) 252-0436
Mailing address
2024 85TH AVE N, BROOKLYN PARK, MN 55444-1495
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
124775
MN
Other
Enumeration date
08/25/2020
Last updated
08/25/2020
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