Healthcare Provider Details

I. General information

NPI: 1124631668
Provider Name (Legal Business Name): PETER MEVISSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 HENNEPIN AVE
MINNEAPOLIS MN
55408-1149
US

IV. Provider business mailing address

2650 HENNEPIN AVE
MINNEAPOLIS MN
55408-1149
US

V. Phone/Fax

Practice location:
  • Phone: 612-377-3308
  • Fax:
Mailing address:
  • Phone: 763-242-7465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number124634
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: