Provider Demographics
NPI:1790349454
Name:LJOSENVOOR, MARIE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:LJOSENVOOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:DEER RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56636-0038
Mailing Address - Country:US
Mailing Address - Phone:218-246-8642
Mailing Address - Fax:218-246-9328
Practice Address - Street 1:2 DIVISION ST STE A
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-8779
Practice Address - Country:US
Practice Address - Phone:218-246-8642
Practice Address - Fax:218-246-9328
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20755-40OtherWISCONSIN PHARMACIST LICENSE
MN122468OtherMINNESOTA PHARMACIST LICENSE
NE14920OtherNEBRASKA PHARMACIST LICENSE