=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225315112
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALAN G SIEBERT RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2011
-----------------------------------------------------
Last Update Date | 11/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1123 E BLUE EARTH AVE
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56031-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-235-5965
-----------------------------------------------------
Fax | 507-235-9385
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1123 E BLUE EARTH AVE
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56031-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-235-5965
-----------------------------------------------------
Fax | 507-235-9385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 114106
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------