Healthcare Provider Details

I. General information

NPI: 1730002320
Provider Name (Legal Business Name): CODY STAYDOHAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3517 E BELTLINE
HIBBING MN
55746-2337
US

IV. Provider business mailing address

428 1ST ST
NASHWAUK MN
55769-1204
US

V. Phone/Fax

Practice location:
  • Phone: 218-262-6140
  • Fax:
Mailing address:
  • Phone: 218-969-7017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number127452
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: