=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629364450
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN K IVERSON RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2011
-----------------------------------------------------
Last Update Date | 01/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1520 20TH AVE SW
-----------------------------------------------------
City | MINOT
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58701-6456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-852-4068
-----------------------------------------------------
Fax | 701-852-6018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1520 20TH AVE SW
-----------------------------------------------------
City | MINOT
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58701-6456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-852-4068
-----------------------------------------------------
Fax | 701-852-6018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 6728
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 4297
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------