Provider Demographics
NPI:1447518493
Name:ERICKSON, CHARLES PAUL (RPH)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:PAUL
Last Name:ERICKSON
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 1:204 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-9449
Mailing Address - Country:US
Mailing Address - Phone:715-483-0260
Mailing Address - Fax:715-483-0516
Practice Address - Street 1:1504 190TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-7102
Practice Address - Country:US
Practice Address - Phone:715-825-4498
Practice Address - Fax:715-825-4499
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112562183500000X
WI155110-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN112562OtherPHARMACIST LICENSE
WI155110-40OtherPHARMACIST LICENSE