Healthcare Provider Details

I. General information

NPI: 1194877670
Provider Name (Legal Business Name): WALTER SPIESE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 1ST AVE. SW
LAMOURE ND
58458-0175
US

IV. Provider business mailing address

PO BOX 175 220 3RD AVE. NE
LAMOURE ND
58458-0175
US

V. Phone/Fax

Practice location:
  • Phone: 701-883-5339
  • Fax: 701-883-5531
Mailing address:
  • Phone: 701-883-5700
  • Fax: 701-883-5531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2974
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: