Provider Demographics
NPI:1922772631
Name:IVERSON, COLTON (PHARMD)
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:
Last Name:IVERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 38TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:317 7TH ST NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633-3359
Practice Address - Country:US
Practice Address - Phone:218-335-3293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH6330183500000X
MN125285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist