Provider Demographics
NPI:1295057412
Name:EBERT, PAUL RICHARD (RPH)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:RICHARD
Last Name:EBERT
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 1:18586 224TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-4672
Mailing Address - Country:US
Mailing Address - Phone:763-262-0999
Mailing Address - Fax:
Practice Address - Street 1:323 JACKSON AVE NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-2523
Practice Address - Country:US
Practice Address - Phone:763-441-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115008183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist