Provider Demographics
NPI:1578175923
Name:PEDERSON-LINN, GLEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:PEDERSON-LINN
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 1:1270 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5228
Mailing Address - Country:US
Mailing Address - Phone:507-388-1315
Mailing Address - Fax:
Practice Address - Street 1:1270 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5228
Practice Address - Country:US
Practice Address - Phone:507-388-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist