MEDICARE: WILLIAM JOHN LASALLE R.PH.

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
1	183500000X	Pharmacist	114363	MN

General Provider Information

NPI Number	:	1790125524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM JOHN LASALLE R.PH.

Provider Business Mailing Address
First Line	:	201 HORACE AVE N
Second Line	:
City	:	THIEF RIVER FALLS
State	:	MN
Zip	:	56701-2024
Country	:	US
Telephone Number	:	218-681-3132
Fax Number	:	218-681-5041

Provider Business Practice Location Address
First Line	:	201 HORACE AVE N
Second Line	:
City	:	THIEF RIVER FALLS
State	:	MN
Zip	:	56701-2024
Country	:	US
Telephone Number	:	218-681-3132
Fax Number	:	218-681-5041

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2013
Last Update Date	:	06/25/2013

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