MEDICARE: MR. ANIS BEN TAHAR R.PH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	120871	MN

General Provider Information

NPI Number	:	1558605550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANIS BEN TAHAR R.PH

Provider Business Mailing Address
First Line	:	11461 N SHORE DR
Second Line	:
City	:	GRANTSBURG
State	:	WI
Zip	:	54840-8059
Country	:	US
Telephone Number	:	612-272-3750
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 W MADISON AVE
Second Line	:
City	:	GRANTSBURG
State	:	WI
Zip	:	54840-7022
Country	:	US
Telephone Number	:	612-272-3750
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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