Provider Demographics
NPI:1891271334
Name:LO, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:LO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 38TH ST N STE A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2953
Mailing Address - Country:US
Mailing Address - Phone:888-558-9941
Mailing Address - Fax:
Practice Address - Street 1:706 38TH ST N STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2953
Practice Address - Country:US
Practice Address - Phone:888-558-9941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH6054183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist