Healthcare Provider Details

I. General information

NPI: 1811500093
Provider Name (Legal Business Name): NAOMI SPERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5474 MOUNTAIN IRON DR
VIRGINIA MN
55792-3371
US

IV. Provider business mailing address

5474 MOUNTAIN IRON DR
VIRGINIA MN
55792-3371
US

V. Phone/Fax

Practice location:
  • Phone: 218-741-2421
  • Fax:
Mailing address:
  • Phone: 218-741-2421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number124420
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: