=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619316031
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN MARIE MADDEN RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2013
-----------------------------------------------------
Last Update Date | 06/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4570 COUNTY HWY 61
-----------------------------------------------------
City | MOOSE LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-485-2111
-----------------------------------------------------
Fax | 218-485-8256
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4240 COUNTY ROAD 11
-----------------------------------------------------
City | BARNUM
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55707-8731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-389-0094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 114553
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------