MEDICARE: CHANTRA PROM PHARMD

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	121468	MN

General Provider Information

NPI Number	:	1992197107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANTRA PROM PHARMD

Provider Business Mailing Address
First Line	:	7940 PENN AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55431-1315
Country	:	US
Telephone Number	:	952-252-1154
Fax Number	:	952-252-1157

Provider Business Practice Location Address
First Line	:	7940 PENN AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55431-1315
Country	:	US
Telephone Number	:	952-252-1154
Fax Number	:	952-252-1157

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

Provider Enumeration Date	:	02/25/2015
Last Update Date	:	02/25/2015

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Directions to “ CHANTRA PROM PHARMD” Practice Location

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