Provider Demographics
NPI:1558778431
Name:DORIC, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DORIC
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 1:701 DELLWOOD ST S
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1920
Mailing Address - Country:US
Mailing Address - Phone:637-689-8700
Mailing Address - Fax:763-689-7816
Practice Address - Street 1:19200 N KELSEY ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1431
Practice Address - Country:US
Practice Address - Phone:360-805-4706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-12
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122182183500000X
WAIR60471093390200000X
WAPH60482605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program