Provider Demographics
NPI:1528892791
Name:FAULKNER, PAUL JACOB (PHARMD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:JACOB
Last Name:FAULKNER
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 1:1109 DEWEY AVE NE APT 3
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3901
Mailing Address - Country:US
Mailing Address - Phone:574-807-1115
Mailing Address - Fax:
Practice Address - Street 1:24760 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-2825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID72611781835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care