Provider Demographics
NPI:1255755310
Name:STANG, MARK SIMON (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:SIMON
Last Name:STANG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 333
Mailing Address - Street 2:309 CYPRESS DRIVE
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MN
Mailing Address - Zip Code:56374-0333
Mailing Address - Country:US
Mailing Address - Phone:320-282-6127
Mailing Address - Fax:
Practice Address - Street 1:309 CYPRESS DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MN
Practice Address - Zip Code:56374-4683
Practice Address - Country:US
Practice Address - Phone:320-282-6127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116267OtherMINNESOTA BOARD OF PHARMACY