Provider Demographics
NPI:1134413081
Name:FUNK, MICHAEL DEAN (BS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:FUNK
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 S POKEGAMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2507
Mailing Address - Country:US
Mailing Address - Phone:218-326-6412
Mailing Address - Fax:218-326-6412
Practice Address - Street 1:2140 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2507
Practice Address - Country:US
Practice Address - Phone:218-326-6412
Practice Address - Fax:218-326-6412
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist