Healthcare Provider Details

I. General information

NPI: 1548682354
Provider Name (Legal Business Name): MICHAEL ANGELO EANNELLI PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

IV. Provider business mailing address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

V. Phone/Fax

Practice location:
  • Phone: 218-927-2121
  • Fax: 218-927-5551
Mailing address:
  • Phone: 218-927-2121
  • Fax: 218-927-5551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number121432
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: