Provider Demographics
NPI:1386032654
Name:MAHOWALD, JIM
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:MAHOWALD
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 1:220 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist