1164454146 NPI number — FAIRVIEW PHARMACY SERVICES LLC

Table of content: (NPI 1164454146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164454146 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 NORTHLAND PHARMACY ELK RIVER
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:
1164454146
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NW 7429
Provider Second Line Business Mailing Address:
PO BOX 1450
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55485-7429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-672-5139
Provider Business Mailing Address Fax Number:
612-672-6545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 MAIN ST NW STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELK RIVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55330-1272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-241-5890
Provider Business Practice Location Address Fax Number:
763-241-5891
Provider Enumeration Date:
07/07/2006

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: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 262541 , 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)

  • Identifier: 2047395 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1164454146 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 757653600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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