Basic Information
| Provider Information | |||||||||
| NPI: | 1154067460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALOGA | ||||||||
| FirstName: | BRIANNE | ||||||||
| MiddleName: | JOAN | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12821 EXECUTIVE ACRES RD | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564015262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512769017 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13060 ISLE DR | ||||||||
| Address2: | |||||||||
| City: | BAXTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564258331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188282880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2022 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 14900-40 | WI | N | Pharmacy Service Providers | Pharmacist | 183500000X | 118851 | MN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.