Healthcare Provider Details

I. General information

NPI: 1710968623
Provider Name (Legal Business Name): DALE KEITH EADS RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1948 DORATHEA BLVD
WORTHINGTON MN
56187-1404
US

IV. Provider business mailing address

1948 DORATHEA BLVD
WORTHINGTON MN
56187-1404
US

V. Phone/Fax

Practice location:
  • Phone: 507-372-4670
  • Fax:
Mailing address:
  • Phone: 507-372-4670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number112504-9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: