Healthcare Provider Details

I. General information

NPI: 1003947060
Provider Name (Legal Business Name): SIVERSON PHARMACY AND GIFTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 SOUTH MAIN ST
HENDRICKS MN
56136-1230
US

IV. Provider business mailing address

118 SOUTH MAIN ST PO BOX 65
HENDRICKS MN
56136-0065
US

V. Phone/Fax

Practice location:
  • Phone: 507-275-3323
  • Fax: 507-275-3810
Mailing address:
  • Phone: 507-275-3323
  • Fax: 507-275-3810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number9491302
License Number StateMN

VIII. Authorized Official

Name: DR. SLADE ANDREW SIVERSON
Title or Position: OWNER/CHIEF PHARMACIST
Credential: PHARM D
Phone: 507-275-3323