Provider Demographics
NPI:1346304219
Name:NELSON, MARK DOUGLAS (R PH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:NELSON
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MINDY CRK
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-9413
Mailing Address - Country:US
Mailing Address - Phone:715-483-3152
Mailing Address - Fax:
Practice Address - Street 1:5200 FAIRVIEW BLVD
Practice Address - Street 2:PHARMACY
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8013
Practice Address - Country:US
Practice Address - Phone:651-982-7237
Practice Address - Fax:651-982-7236
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112843-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist