Healthcare Provider Details

I. General information

NPI: 1538639786
Provider Name (Legal Business Name): KORY KOWALSKI PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 25TH ST S
FARGO ND
58103-6171
US

IV. Provider business mailing address

103 14TH AVE S
MOORHEAD MN
56560-4040
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-6022
  • Fax: 701-293-6040
Mailing address:
  • Phone: 218-790-1482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number120806
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH5550
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: