Provider Demographics
NPI:1902489651
Name:MATTILA, ALICE (PHARMD)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:MATTILA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 UNION TERRACE LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-1523
Mailing Address - Country:US
Mailing Address - Phone:612-666-2232
Mailing Address - Fax:
Practice Address - Street 1:10132 W 76TH ST
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3728
Practice Address - Country:US
Practice Address - Phone:877-323-4292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1211821835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy