Healthcare Provider Details

I. General information

NPI: 1396400396
Provider Name (Legal Business Name): SEAN ANSOLABEHERE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 1ST ST S
WILLMAR MN
56201-4212
US

IV. Provider business mailing address

235 STATE HIGHWAY 55 N
GLENWOOD MN
56334-1957
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-1930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number125454
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: