Provider Demographics
NPI:1225355795
Name:SMESTAD, JON M (RPH)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:M
Last Name:SMESTAD
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 1:404 SCHILLING DR N
Mailing Address - Street 2:PO BOX 100
Mailing Address - City:DUNDAS
Mailing Address - State:MN
Mailing Address - Zip Code:55019-3968
Mailing Address - Country:US
Mailing Address - Phone:507-645-5855
Mailing Address - Fax:507-645-9746
Practice Address - Street 1:404 SCHILLING DR N
Practice Address - Street 2:
Practice Address - City:DUNDAS
Practice Address - State:MN
Practice Address - Zip Code:55019-3968
Practice Address - Country:US
Practice Address - Phone:507-645-5855
Practice Address - Fax:507-645-9746
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114807183500000X
KY9569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN196217500Medicaid