Provider Demographics
NPI:1952706483
Name:MCCONVILLE, MOLLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MCCONVILLE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:MN
Mailing Address - Zip Code:56097-1633
Mailing Address - Country:US
Mailing Address - Phone:507-553-3161
Mailing Address - Fax:
Practice Address - Street 1:36 S BROADWAY
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:MN
Practice Address - Zip Code:56097-1633
Practice Address - Country:US
Practice Address - Phone:507-553-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121659183500000X
ND5582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist