Provider Demographics
NPI:1588211015
Name:NYSTROM, ROBERT SCOTT (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SCOTT
Last Name:NYSTROM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3393
Mailing Address - Country:US
Mailing Address - Phone:218-825-1099
Mailing Address - Fax:
Practice Address - Street 1:209 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3393
Practice Address - Country:US
Practice Address - Phone:218-829-3529
Practice Address - Fax:218-829-1861
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist