Healthcare Provider Details

I. General information

NPI: 1104136837
Provider Name (Legal Business Name): STEPHEN JAMES SYVERSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 13TH AVE E
WEST FARGO ND
58078-3360
US

IV. Provider business mailing address

3116 18TH ST S
FARGO ND
58103-6718
US

V. Phone/Fax

Practice location:
  • Phone: 701-373-0685
  • Fax:
Mailing address:
  • Phone: 701-388-5832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5239
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: