Provider Demographics
NPI:1417586983
Name:FAGERNESS, RICHARD MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:FAGERNESS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13316 311TH AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-3649
Mailing Address - Country:US
Mailing Address - Phone:320-282-1080
Mailing Address - Fax:
Practice Address - Street 1:2420 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3926
Practice Address - Country:US
Practice Address - Phone:320-253-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN113836OtherSTATE LICENSE