=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962893438
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIHAIL YAKOVLEV
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2015
-----------------------------------------------------
Last Update Date | 02/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8225 FLYING CLOUD DR
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55344-5315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-944-8720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17156 EASTWOOD AVE
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55024-7337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-261-9611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | 728689
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------