MEDICARE: DANIEL BEN MOLSTAD RPH

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	9148040	WI

General Provider Information

NPI Number	:	1902940141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL BEN MOLSTAD RPH

Provider Business Mailing Address
First Line	:	15520 GOLF RD
Second Line	:
City	:	ETTRICK
State	:	WI
Zip	:	54627-7839
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 W BROADWAY ST
Second Line	:
City	:	BLAIR
State	:	WI
Zip	:	54616-9367
Country	:	US
Telephone Number	:	608-989-2919
Fax Number	:	608-989-2837

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

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	07/25/2007

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