Provider Demographics
NPI:1902991318
Name:FOSSEN, JOHN E (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:FOSSEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MINN AVE S
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431
Mailing Address - Country:US
Mailing Address - Phone:218-927-3754
Mailing Address - Fax:218-927-6349
Practice Address - Street 1:124 MINN AVE N
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431
Practice Address - Country:US
Practice Address - Phone:218-927-3754
Practice Address - Fax:218-927-6349
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1104675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist