Provider Demographics
NPI:1992304083
Name:EBELING, BRETA (PHARMD, RN)
Entity type:Individual
Prefix:
First Name:BRETA
Middle Name:
Last Name:EBELING
Suffix:
Gender:F
Credentials:PHARMD, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 TOWN CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2310
Mailing Address - Country:US
Mailing Address - Phone:651-686-7431
Mailing Address - Fax:651-686-7433
Practice Address - Street 1:1360 TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2310
Practice Address - Country:US
Practice Address - Phone:651-686-7431
Practice Address - Fax:651-686-7433
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119025183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist