Provider Demographics
NPI:1295091866
Name:PARKS, THERESA MARIE (MS)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:PARKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8949 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-8000
Mailing Address - Country:US
Mailing Address - Phone:763-786-6820
Mailing Address - Fax:763-786-3276
Practice Address - Street 1:8949 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-8000
Practice Address - Country:US
Practice Address - Phone:763-786-6820
Practice Address - Fax:763-786-3276
Is Sole Proprietor?:No
Enumeration Date:2012-04-07
Last Update Date:2012-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist