Provider Demographics
NPI:1073811766
Name:NELSON, LANE M (RPH)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
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:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:EDGELEY
Mailing Address - State:ND
Mailing Address - Zip Code:58433-0025
Mailing Address - Country:US
Mailing Address - Phone:701-493-2810
Mailing Address - Fax:701-493-2856
Practice Address - Street 1:509 MAIN ST
Practice Address - Street 2:
Practice Address - City:EDGELEY
Practice Address - State:ND
Practice Address - Zip Code:58433
Practice Address - Country:US
Practice Address - Phone:701-493-2810
Practice Address - Fax:701-493-2856
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist