Provider Demographics
NPI:1356949028
Name:MACK, DARREN GAROLD (PHARM D)
Entity type:Individual
Prefix:
First Name:DARREN
Middle Name:GAROLD
Last Name:MACK
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2114
Mailing Address - Country:US
Mailing Address - Phone:218-234-7942
Mailing Address - Fax:
Practice Address - Street 1:1583 HIGHWAY 10 W
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2232
Practice Address - Country:US
Practice Address - Phone:218-847-7225
Practice Address - Fax:218-847-8307
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist