Provider Demographics
NPI:1265709182
Name:WERMERS, MARK DAVID (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:WERMERS
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 1:11340 47TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2904
Mailing Address - Country:US
Mailing Address - Phone:763-550-1872
Mailing Address - Fax:
Practice Address - Street 1:4200 WINNETKA AVE
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428
Practice Address - Country:US
Practice Address - Phone:763-545-6466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115179183500000X
AZS008141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist