Provider Demographics
NPI:1962771642
Name:LIGHT, DAVID JOHN (RPH)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JOHN
Last Name:LIGHT
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 1:6483 36TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-9409
Mailing Address - Country:US
Mailing Address - Phone:320-656-5830
Mailing Address - Fax:
Practice Address - Street 1:17 DIVISION ST
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1349
Practice Address - Country:US
Practice Address - Phone:320-203-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-24
Last Update Date:2011-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist