Provider Demographics
NPI:1174740849
Name:HALVERSON, VALERIE (RPH)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43935 FORESTRY RD
Mailing Address - Street 2:
Mailing Address - City:BOVEY
Mailing Address - State:MN
Mailing Address - Zip Code:55709-5527
Mailing Address - Country:US
Mailing Address - Phone:218-327-9527
Mailing Address - Fax:218-326-9525
Practice Address - Street 1:2410 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2503
Practice Address - Country:US
Practice Address - Phone:218-326-9089
Practice Address - Fax:218-326-9525
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116120183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116120OtherPHARMACIST LICENSE NUMBER