Provider Demographics
NPI:1871195842
Name:HENRIKSEN, MARIA NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:NICOLE
Last Name:HENRIKSEN
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 1:1310 21ST AVE NW UNIT 414
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-3661
Mailing Address - Country:US
Mailing Address - Phone:612-412-3197
Mailing Address - Fax:
Practice Address - Street 1:1307 18TH AVE NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-1996
Practice Address - Country:US
Practice Address - Phone:507-437-9185
Practice Address - Fax:507-433-7067
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist