Provider Demographics
NPI:1861775801
Name:HALVERSON, WES
Entity type:Individual
Prefix:
First Name:WES
Middle Name:
Last Name:HALVERSON
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 1:6025 SHENANDOAH LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-4557
Mailing Address - Country:US
Mailing Address - Phone:763-252-1300
Mailing Address - Fax:763-252-1306
Practice Address - Street 1:6025 SHENANDOAH LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-4557
Practice Address - Country:US
Practice Address - Phone:763-252-1300
Practice Address - Fax:763-252-1306
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist