Basic Information
| Provider Information | |||||||||
| NPI: | 1639152119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRUND | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | R.PH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24760 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566713106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186792825 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24760 HOSPITAL DR NW | ||||||||
| Address2: | |||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566713106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186792825 | ||||||||
| FaxNumber: | 2186790189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 115362-6 | MN | N | Pharmacy Service Providers | Pharmacist | 1835P0018X | 115362 | MN | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.