Healthcare Provider Details

I. General information

NPI: 1265709182
Provider Name (Legal Business Name): MARK DAVID WERMERS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WINNETKA AVE
NEW HOPE MN
55428
US

IV. Provider business mailing address

11340 47TH AVE N
PLYMOUTH MN
55442-2904
US

V. Phone/Fax

Practice location:
  • Phone: 763-545-6466
  • Fax:
Mailing address:
  • Phone: 763-550-1872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number115179
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS008141
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: