Provider Demographics
NPI:1346839164
Name:RUPRECHT, TANNER MARK
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:MARK
Last Name:RUPRECHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16502 77TH CIR N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3733
Mailing Address - Country:US
Mailing Address - Phone:763-732-3103
Mailing Address - Fax:
Practice Address - Street 1:16502 77TH CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-3733
Practice Address - Country:US
Practice Address - Phone:763-732-3103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist