Provider Demographics
NPI:1407058332
Name:ICE, JOAN L (R PH)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:L
Last Name:ICE
Suffix:
Gender:F
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 1:43500 MIGIZI DR
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-2241
Mailing Address - Country:US
Mailing Address - Phone:620-532-4770
Mailing Address - Fax:320-532-4705
Practice Address - Street 1:43500 MIGIZI DR
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-2241
Practice Address - Country:US
Practice Address - Phone:320-532-4770
Practice Address - Fax:320-532-4705
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist