Provider Demographics
NPI:1215937099
Name:DYRSTAD, MARVIN LEROY (RPH)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:LEROY
Last Name:DYRSTAD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2432
Mailing Address - Country:US
Mailing Address - Phone:651-388-6883
Mailing Address - Fax:651-388-6796
Practice Address - Street 1:910 W 6TH ST
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2432
Practice Address - Country:US
Practice Address - Phone:651-388-6883
Practice Address - Fax:651-388-6796
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110761-4183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist