Healthcare Provider Details

I. General information

NPI: 1174528855
Provider Name (Legal Business Name): RANAE MARIE SPORE PHARMACY TEC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 8 1/2 STREET
STARBUCK MN
56381-0154
US

IV. Provider business mailing address

PO BOX 154
STARBUCK MN
56381-0154
US

V. Phone/Fax

Practice location:
  • Phone: 320-239-2246
  • Fax: 320-239-2296
Mailing address:
  • Phone: 320-239-2246
  • Fax: 320-239-2296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number700468-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: