Healthcare Provider Details

I. General information

NPI: 1134379845
Provider Name (Legal Business Name): KATI JEAN DVORAK PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HIGHWAY 65 S
MORA MN
55051-1899
US

IV. Provider business mailing address

301 HIGHWAY 65 S
MORA MN
55051-1899
US

V. Phone/Fax

Practice location:
  • Phone: 320-225-3597
  • Fax:
Mailing address:
  • Phone: 320-679-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number119338
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: