Provider Demographics
NPI:1437740040
Name:MICKELSON, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MICKELSON
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:PO BOX 745
Mailing Address - Street 2:
Mailing Address - City:PIPESTONE
Mailing Address - State:MN
Mailing Address - Zip Code:56164-0745
Mailing Address - Country:US
Mailing Address - Phone:507-825-4259
Mailing Address - Fax:
Practice Address - Street 1:802 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:PIPESTONE
Practice Address - State:MN
Practice Address - Zip Code:56164-1734
Practice Address - Country:US
Practice Address - Phone:507-825-4259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist