Provider Demographics
NPI:1750535290
Name:SERGOT, DANIELLE BEAUDETTE (PHARMD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:BEAUDETTE
Last Name:SERGOT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:MARIE
Other - Last Name:BEAUDETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD, MBA, BCACP
Mailing Address - Street 1:1542 GOLF COURSE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3537
Mailing Address - Country:US
Mailing Address - Phone:218-322-6210
Mailing Address - Fax:218-322-6211
Practice Address - Street 1:1542 GOLF COURSE RD STE 205
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-322-6210
Practice Address - Fax:970-322-6211
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18014183500000X
MN123222183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist