Healthcare Provider Details

I. General information

NPI: 1477063303
Provider Name (Legal Business Name): BETHANY ROSE TALATALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2795 PILOT KNOB RD
EAGAN MN
55121-1176
US

IV. Provider business mailing address

4525 NATHAN LN N APT 304
PLYMOUTH MN
55442-3151
US

V. Phone/Fax

Practice location:
  • Phone: 651-846-9245
  • Fax:
Mailing address:
  • Phone: 763-242-2407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number731491
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: