Provider Demographics
NPI:1124633557
Name:DU PRE, JOHN LEE
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LEE
Last Name:DU PRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18525 COUNTY ROAD 24
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-1051
Mailing Address - Country:US
Mailing Address - Phone:952-594-2170
Mailing Address - Fax:
Practice Address - Street 1:4950 COUNTY ROAD 101
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-2637
Practice Address - Country:US
Practice Address - Phone:952-938-3566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122648OtherMNBOP