Provider Demographics
NPI:1336360494
Name:CARLSON, ELISE ROSE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:ROSE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6562 CHRISTIANSON PARKWAY S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-3326
Mailing Address - Country:US
Mailing Address - Phone:701-866-8843
Mailing Address - Fax:
Practice Address - Street 1:720 4TH ST N
Practice Address - Street 2:ROUTE 204
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0204
Practice Address - Country:US
Practice Address - Phone:701-234-5606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5080183500000X
MN119194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist