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NPI Code Detail

MEDICARE: MADILYN BOMMERSBACH PHARMD

MEDICARE: MADILYN BOMMERSBACH PHARMD
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
1183500000XPharmacist125700MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1125700OTHERMNBOARD OF PHARMACY

General Provider Information

NPI Number : 1629705280
Entity Type Code : Individual
Provider Name (Legal Business Name) : MADILYN BOMMERSBACH PHARMD
Provider Business Mailing Address
First Line : 100 8TH AVE S UNIT 312
Second Line :
City : HOPKINS
State : MN
Zip : 55343-4609
Country : US
Telephone Number : 701-535-0484
Fax Number :
Provider Business Practice Location Address
First Line : 3620 TEXAS AVE S
Second Line :
City : ST LOUIS PARK
State : MN
Zip : 55426-4057
Country : US
Telephone Number : 952-933-3177
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/03/2022
Last Update Date : 08/03/2022

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Directions to “ MADILYN BOMMERSBACH PHARMD” Practice Location

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