Healthcare Provider Details

I. General information

NPI: 1871581504
Provider Name (Legal Business Name): CHARLES FREDSON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 TRETTEL LN
CLOQUET MN
55720-1345
US

IV. Provider business mailing address

29 BIRCH DR
ESKO MN
55733-9642
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-1227
  • Fax: 218-878-3739
Mailing address:
  • Phone: 218-879-9746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number111631-7
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: