1124684634 NPI number — COBORNS INC

Table of content: (NPI 1124684634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124684634 NPI number — COBORNS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COBORNS INC
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:
COBORN'S CENTRAL SUPPORT PHARMACY #9942
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:
1124684634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6146
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56302-6146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-534-2745
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 1ST ST S STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAUK RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56379-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-202-8343
Provider Business Practice Location Address Fax Number:
320-202-8341
Provider Enumeration Date:
05/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
NELLIS
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
320-534-2743

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2434532 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1124684634 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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