Provider Demographics
NPI:1215559877
Name:PERRY, MADISSON (PHARMD)
Entity Type:Individual
Prefix:
First Name:MADISSON
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2527
Mailing Address - Country:US
Mailing Address - Phone:612-872-2656
Mailing Address - Fax:612-872-8301
Practice Address - Street 1:2001 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2527
Practice Address - Country:US
Practice Address - Phone:612-872-2656
Practice Address - Fax:612-872-8301
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-17
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1043497993Medicaid