Healthcare Provider Details

I. General information

NPI: 1649924523
Provider Name (Legal Business Name): PETER E. SANDELIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4621 E SUPERIOR ST
DULUTH MN
55804-2338
US

IV. Provider business mailing address

4621 E SUPERIOR ST
DULUTH MN
55804-2338
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-3784
  • Fax: 218-525-7338
Mailing address:
  • Phone: 218-786-3784
  • Fax: 218-525-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number119517
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: