Healthcare Provider Details

I. General information

NPI: 1639455041
Provider Name (Legal Business Name): JOEL SKOOG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2011
Last Update Date: 10/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 MARKETPLACE DR N
CHAMPLIN MN
55316-3794
US

IV. Provider business mailing address

11401 MARKETPLACE DR N
CHAMPLIN MN
55316-3794
US

V. Phone/Fax

Practice location:
  • Phone: 763-427-6389
  • Fax:
Mailing address:
  • Phone: 763-427-6389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number118505
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: