Provider Demographics
NPI:1669084802
Name:WERTH, CALVIN GAYLE
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:GAYLE
Last Name:WERTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 LEXINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4220 LEXINGTON AVE S
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1975
Practice Address - Country:US
Practice Address - Phone:651-686-1090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist