Provider Demographics
NPI:1639152119
Name:GRUND, TERESA RENAE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:RENAE
Last Name:GRUND
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24760 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-3106
Mailing Address - Country:US
Mailing Address - Phone:218-679-2825
Mailing Address - Fax:
Practice Address - Street 1:24760 HOSPITAL DR NW
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671-3106
Practice Address - Country:US
Practice Address - Phone:218-679-2825
Practice Address - Fax:218-679-0189
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115362-6183500000X
MN1153621835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist