Provider Demographics
NPI:1073951950
Name:GRUENEICH, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GRUENEICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2216
Mailing Address - Country:US
Mailing Address - Phone:218-736-5565
Mailing Address - Fax:
Practice Address - Street 1:4255 30TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8427
Practice Address - Country:US
Practice Address - Phone:701-478-8122
Practice Address - Fax:701-478-8127
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119577183500000X
NDRPH5639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist