1902390008 NPI number — ELISE NICOLE DURGIN PHARMD, BCPS

Table of content: CORY A LARSEN RPH (NPI 1740321348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902390008 NPI number — ELISE NICOLE DURGIN PHARMD, BCPS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DURGIN
Provider First Name:
ELISE
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD, BCPS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEAD
Provider Other First Name:
ELISE
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902390008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 E MAIN ST
Provider Second Line Business Mailing Address:
CUYUNA LAKES PHARMACY
Provider Business Mailing Address City Name:
CROSBY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-546-2345
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROSBY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56441-1645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-546-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  123773 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com