Provider Demographics
NPI:1053520916
Name:DWORSHAK, CLINT M (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CLINT
Middle Name:M
Last Name:DWORSHAK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16908 SADDLEWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2672
Mailing Address - Country:US
Mailing Address - Phone:952-935-9227
Mailing Address - Fax:
Practice Address - Street 1:5534 LAKELAND AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3121
Practice Address - Country:US
Practice Address - Phone:763-259-0188
Practice Address - Fax:888-636-9971
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117076-4183500000X
ND4803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN117076-4OtherMN PHARMACIST LICENSE
ND4803OtherND PHARMACIST LICENSE