Provider Demographics
NPI:1043705965
Name:MELLGREN, DANE JOHN (PHARMD)
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:JOHN
Last Name:MELLGREN
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 1:4429 VAN BUREN ST NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-2952
Mailing Address - Country:US
Mailing Address - Phone:952-451-4838
Mailing Address - Fax:
Practice Address - Street 1:4429 VAN BUREN ST NE
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-2952
Practice Address - Country:US
Practice Address - Phone:952-451-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123330183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist