Provider Demographics
NPI:1255852745
Name:IVERSON, ZACHARIAH DALE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARIAH
Middle Name:DALE
Last Name:IVERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 260TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARVIN
Mailing Address - State:MN
Mailing Address - Zip Code:56132-9778
Mailing Address - Country:US
Mailing Address - Phone:507-828-8234
Mailing Address - Fax:
Practice Address - Street 1:131 3RD ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:MN
Practice Address - Zip Code:56175-1211
Practice Address - Country:US
Practice Address - Phone:507-629-3801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6490183500000X
MN123312183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist