MEDICARE: MRS. TERESA RENAE GRUND 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	115362-6	MN
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	115362	MN

General Provider Information

NPI Number	:	1639152119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESA RENAE GRUND R.PH

Provider Business Mailing Address
First Line	:	24760 HOSPITAL DR
Second Line	:
City	:	RED LAKE
State	:	MN
Zip	:	56671-3106
Country	:	US
Telephone Number	:	218-679-2825
Fax Number	:

Provider Business Practice Location Address
First Line	:	24760 HOSPITAL DR NW
Second Line	:
City	:	RED LAKE
State	:	MN
Zip	:	56671-3106
Country	:	US
Telephone Number	:	218-679-2825
Fax Number	:	218-679-0189

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

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	10/17/2019

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