Healthcare Provider Details

I. General information

NPI: 1417586983
Provider Name (Legal Business Name): RICHARD MICHAEL FAGERNESS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 W DIVISION ST
SAINT CLOUD MN
56301-3926
US

IV. Provider business mailing address

13316 311TH AVE
PRINCETON MN
55371-3649
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5366
  • Fax:
Mailing address:
  • Phone: 320-282-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number113836
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: