Healthcare Provider Details

I. General information

NPI: 1730195306
Provider Name (Legal Business Name): MICHELLE GERISE-KOOPMEINERS ETTEL R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

213 MUSTANG LN
MELROSE MN
56352-1388
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-6465
  • Fax: 320-255-6360
Mailing address:
  • Phone: 320-256-5166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number115240-7
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: