Provider Demographics
NPI:1053916510
Name:CARLSON, GERILYNN (RPH)
Entity type:Individual
Prefix:
First Name:GERILYNN
Middle Name:
Last Name:CARLSON
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 1:1616 9TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4119
Mailing Address - Country:US
Mailing Address - Phone:701-306-8140
Mailing Address - Fax:
Practice Address - Street 1:1321 19TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-1821
Practice Address - Country:US
Practice Address - Phone:701-232-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist