Provider Demographics
NPI:1417623307
Name:FAKE, KALLEY ANNE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:KALLEY
Middle Name:ANNE
Last Name:FAKE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KALLEY
Other - Middle Name:ANNE
Other - Last Name:PEDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1315 HIGHWAY 25 N
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1315 HIGHWAY 25 N
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1937
Practice Address - Country:US
Practice Address - Phone:763-682-2963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125353183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist