Provider Demographics
NPI:1578036224
Name:AXTELL, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:AXTELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-6026
Mailing Address - Country:US
Mailing Address - Phone:320-322-5141
Mailing Address - Fax:320-322-5132
Practice Address - Street 1:301 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1899
Practice Address - Country:US
Practice Address - Phone:320-209-1542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-05
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist