MEDICARE: KATHLEEN MARIE ITES

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	115236	MN

General Provider Information

NPI Number	:	1811273782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MARIE ITES

Provider Business Mailing Address
First Line	:	950 COUNTY ROAD 42 W
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-4428
Country	:	US
Telephone Number	:	952-892-7777
Fax Number	:	952-892-0234

Provider Business Practice Location Address
First Line	:	950 COUNTY ROAD 42 W
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-4428
Country	:	US
Telephone Number	:	952-892-7777
Fax Number	:	952-892-0234

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

Provider Enumeration Date	:	10/24/2011
Last Update Date	:	10/24/2011

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