Basic Information
Provider Information | |||||||||
NPI: | 1902886427 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SELLERS | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARM.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7999 WHITE OAK ST NE | ||||||||
Address2: |   | ||||||||
City: | BEMIDJI | ||||||||
State: | MN | ||||||||
PostalCode: | 566017541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2184448838 | ||||||||
FaxNumber: | 2184448980 | ||||||||
Practice Location | |||||||||
Address1: | HIGHWAY 1 | ||||||||
Address2: |   | ||||||||
City: | RED LAKE | ||||||||
State: | MN | ||||||||
PostalCode: | 56671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2186793912 | ||||||||
FaxNumber: | 2186790189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | 16539 | MD | Y |   | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No ID Information.