Healthcare Provider Details

I. General information

NPI: 1316545643
Provider Name (Legal Business Name): BRANDON MORK PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MAIN AVE W
WINSTED MN
55395-7872
US

IV. Provider business mailing address

537 STEVENS ST SW
WATERTOWN MN
55388-9215
US

V. Phone/Fax

Practice location:
  • Phone: 320-485-2555
  • Fax: 320-485-4266
Mailing address:
  • Phone: 612-387-3872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number124618
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: