Healthcare Provider Details

I. General information

NPI: 1114856366
Provider Name (Legal Business Name): MICHELE MEDINA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 7TH ST NE
NEW PRAGUE MN
56071-8101
US

IV. Provider business mailing address

1413 7TH ST NE
NEW PRAGUE MN
56071-8101
US

V. Phone/Fax

Practice location:
  • Phone: 952-212-4024
  • Fax:
Mailing address:
  • Phone: 952-212-4024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number116904
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: