1447341011 NPI number — SOUTHTOWN ECONODRUG

Table of content: THERESA DO TRAN D.O, (NPI 1306165790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447341011 NPI number — SOUTHTOWN ECONODRUG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHTOWN ECONODRUG
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ECONODRUG OTTERTAIL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447341011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 154
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTTERTAIL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56571-0154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-367-2196
Provider Business Mailing Address Fax Number:
218-367-2197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 MN HWY 78 N.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTERTAIL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-367-2196
Provider Business Practice Location Address Fax Number:
218-367-2197
Provider Enumeration Date:
09/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MYRON
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHARMACIST/OWNER
Authorized Official Telephone Number:
218-367-2196

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  262612-3 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)