Provider Demographics
NPI:1689950404
Name:FOSSUM, AMY (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 CHAMBERSBURG DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3201
Mailing Address - Country:US
Mailing Address - Phone:218-724-3948
Mailing Address - Fax:
Practice Address - Street 1:2015 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2538
Practice Address - Country:US
Practice Address - Phone:715-392-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13423-040183500000X
MN117366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist