Healthcare Provider Details

I. General information

NPI: 1962893438
Provider Name (Legal Business Name): MIHAIL YAKOVLEV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8225 FLYING CLOUD DR
EDEN PRAIRIE MN
55344-5315
US

IV. Provider business mailing address

17156 EASTWOOD AVE
FARMINGTON MN
55024-7337
US

V. Phone/Fax

Practice location:
  • Phone: 952-944-8720
  • Fax:
Mailing address:
  • Phone: 952-261-9611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number728689
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: