Provider Demographics
NPI:1205287745
Name:MALSTROM, COREY TODD (PHARMD)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:TODD
Last Name:MALSTROM
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 1:133 SUMMIT ST APT 337
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-4523
Mailing Address - Country:US
Mailing Address - Phone:218-387-1133
Mailing Address - Fax:844-674-6737
Practice Address - Street 1:21 W HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604-4401
Practice Address - Country:US
Practice Address - Phone:218-387-1133
Practice Address - Fax:218-387-2169
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122710183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist