Healthcare Provider Details

I. General information

NPI: 1043786445
Provider Name (Legal Business Name): CAROLYN MAI DER XIONG PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1852 131ST LN NW
COON RAPIDS MN
55448-1385
US

IV. Provider business mailing address

1852 131ST LN NW
COON RAPIDS MN
55448-1385
US

V. Phone/Fax

Practice location:
  • Phone: 763-754-6732
  • Fax: 763-754-6179
Mailing address:
  • Phone: 763-754-6732
  • Fax: 763-754-6179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number123025
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: