Provider Demographics
NPI:1013035450
Name:BORRESEN, BRADLEY DEAN (RPH)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DEAN
Last Name:BORRESEN
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 1:2209 W DREAM DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-2305
Mailing Address - Country:US
Mailing Address - Phone:507-387-3646
Mailing Address - Fax:
Practice Address - Street 1:2010 ADAMS ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6817
Practice Address - Country:US
Practice Address - Phone:507-625-7565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112214183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist