1174635171 NPI number — GOODRICH PHARMACY, INC.

Table of content: (NPI 1174635171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174635171 NPI number — GOODRICH PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOODRICH PHARMACY, 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:
GOODRICH 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:
1174635171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2621 GREENHAVEN RD STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANOKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55303-5566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-441-0764
Provider Business Mailing Address Fax Number:
763-587-4897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 3RD ST NW
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:
55330-1445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-441-0764
Provider Business Practice Location Address Fax Number:
763-587-4897
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-421-5540

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X , with the licence number: 265080 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2046716 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 606360800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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