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NPI Code Detail

MEDICARE: MR. RICHARD MICHAEL FAGERNESS RPH

MEDICARE: MR. RICHARD MICHAEL FAGERNESS RPH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacist113836MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1113836OTHERMNSTATE LICENSE

General Provider Information

NPI Number : 1417586983
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. RICHARD MICHAEL FAGERNESS RPH
Provider Business Mailing Address
First Line : 13316 311TH AVE
Second Line :
City : PRINCETON
State : MN
Zip : 55371-3649
Country : US
Telephone Number : 320-282-1080
Fax Number :
Provider Business Practice Location Address
First Line : 2420 W DIVISION ST
Second Line :
City : SAINT CLOUD
State : MN
Zip : 56301-3926
Country : US
Telephone Number : 320-253-5366
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/06/2020
Last Update Date : 04/06/2020

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