Provider Demographics
NPI:1609239326
Name:KAASA, DOUGLAS (RPH)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:KAASA
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 1:1305 HIGHWAY 10 W
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2214
Mailing Address - Country:US
Mailing Address - Phone:218-847-9755
Mailing Address - Fax:847-747-1701
Practice Address - Street 1:1305 HIGHWAY 10 W
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2214
Practice Address - Country:US
Practice Address - Phone:218-847-9755
Practice Address - Fax:847-747-1701
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115112183500000X
ND3549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN115112OtherMINNESOTA STATE PHARMACY LICENSE