Provider Demographics
NPI:1801675335
Name:KOIVISTO, ROSS ALEKSANDER
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:ALEKSANDER
Last Name:KOIVISTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2221
Mailing Address - Country:US
Mailing Address - Phone:218-724-8825
Mailing Address - Fax:
Practice Address - Street 1:1609 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2221
Practice Address - Country:US
Practice Address - Phone:218-724-8825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist