Provider Demographics
NPI:1902432727
Name:VAN PEURSEM, NICHOLAS ALLEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALLEN
Last Name:VAN PEURSEM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56024-0391
Mailing Address - Country:US
Mailing Address - Phone:605-553-6651
Mailing Address - Fax:
Practice Address - Street 1:1610 MONKS AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5173
Practice Address - Country:US
Practice Address - Phone:507-625-1553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124484183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist