Provider Demographics
NPI:1588812127
Name:CARLSON, MARK CHARLES (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CHARLES
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:CHARLES
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:415 JEFFERSON ST N
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1264
Mailing Address - Country:US
Mailing Address - Phone:218-631-7476
Mailing Address - Fax:
Practice Address - Street 1:415 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1264
Practice Address - Country:US
Practice Address - Phone:218-631-7476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist