Healthcare Provider Details

I. General information

NPI: 1649664020
Provider Name (Legal Business Name): STEPHEN FAGERLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 E 54TH ST N
SIOUX FALLS SD
57104-5563
US

IV. Provider business mailing address

601 E 69TH ST APT 317
SIOUX FALLS SD
57108-2407
US

V. Phone/Fax

Practice location:
  • Phone: 866-744-0621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6182
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: