Healthcare Provider Details

I. General information

NPI: 1740699891
Provider Name (Legal Business Name): TIMOTHY DONALD ACKERMAN PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 E BAY DR
MADISON LAKE MN
56063-1009
US

IV. Provider business mailing address

128 E BAY DR
MADISON LAKE MN
56063-1009
US

V. Phone/Fax

Practice location:
  • Phone: 507-391-0134
  • Fax: 507-243-3094
Mailing address:
  • Phone: 507-391-0134
  • Fax: 507-243-3094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number113000
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS014530
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15882
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16602
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: