Provider Demographics
NPI:1881290419
Name:BREDESON, LANE (RPHT)
Entity type:Individual
Prefix:MR
First Name:LANE
Middle Name:
Last Name:BREDESON
Suffix:
Gender:M
Credentials:RPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:OAKES
Mailing Address - State:ND
Mailing Address - Zip Code:58474-1150
Mailing Address - Country:US
Mailing Address - Phone:701-742-3315
Mailing Address - Fax:
Practice Address - Street 1:422 MAIN AVE
Practice Address - Street 2:
Practice Address - City:OAKES
Practice Address - State:ND
Practice Address - Zip Code:58474-1637
Practice Address - Country:US
Practice Address - Phone:701-742-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPHT1397183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician