Provider Demographics
NPI:1790199768
Name:KLISMET, BECKY
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:KLISMET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 E FRANKLIN AVE
Mailing Address - Street 2:SUITE 13B
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2101
Mailing Address - Country:US
Mailing Address - Phone:612-871-1989
Mailing Address - Fax:612-777-6969
Practice Address - Street 1:1433 E FRANKLIN AVE
Practice Address - Street 2:SUITE 13B
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2101
Practice Address - Country:US
Practice Address - Phone:612-871-1989
Practice Address - Fax:612-777-6969
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist