=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073077061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN DAVID SKLUZACEK PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2019
-----------------------------------------------------
Last Update Date | 01/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 N CENTRAL AVE
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55807-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-624-5773
-----------------------------------------------------
Fax | 218-624-4947
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 N CENTRAL AVE
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55807-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-624-5773
-----------------------------------------------------
Fax | 218-624-4947
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 121827
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------