Provider Demographics
NPI:1164010328
Name:MATHISEN, COLLEEN MARIE
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:MATHISEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8340 153RD PL
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2388
Mailing Address - Country:US
Mailing Address - Phone:952-201-7388
Mailing Address - Fax:
Practice Address - Street 1:540 BLAKE RD N
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-8123
Practice Address - Country:US
Practice Address - Phone:952-938-1168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist