1063615979 NPI number — FAIRVIEW PHARMACY SERVICES LLC

Table of content: (NPI 1063615979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063615979 NPI number — FAIRVIEW PHARMACY SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRVIEW PHARMACY SERVICES LLC
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:
FAIRVIEW MAPLE GROVE CLINIC MTM
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:
1063615979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1450 NW5823
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-898-1810
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14500 99TH AVE N SUITE 1C001
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-898-1810
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FASCHING
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
612-617-3799

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  APPLIED , 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)





Copyright © 2007-2024 www.npivalidator.com