Provider Demographics
NPI:1972101731
Name:STIBBE, FREDERICK MARVIN
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:MARVIN
Last Name:STIBBE
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 1:701 VILLA PARK WAY
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-4364
Mailing Address - Country:US
Mailing Address - Phone:701-200-9483
Mailing Address - Fax:
Practice Address - Street 1:1303 CHARLES ST
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1241
Practice Address - Country:US
Practice Address - Phone:701-200-9483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113776183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist