1487636213 NPI number — MINNESOTA STATE COLLEGES AND UNIVERSITIES

Table of content: (NPI 1487636213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487636213 NPI number — MINNESOTA STATE COLLEGES AND UNIVERSITIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA STATE COLLEGES AND UNIVERSITIES
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:
HEALTH SERVICES PHARMACY
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:
1487636213
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 CARKOSKI CMNS
Provider Second Line Business Mailing Address:
600 MAYWOOD AVE
Provider Business Mailing Address City Name:
MANKATO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56001-6030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-389-2483
Provider Business Mailing Address Fax Number:
507-389-2206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 CARKOSKI CMNS
Provider Second Line Business Practice Location Address:
MINNESOTA STATE UNIVERSITY, MANKATO
Provider Business Practice Location Address City Name:
MANKATO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56001-6030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-389-2483
Provider Business Practice Location Address Fax Number:
507-389-2206
Provider Enumeration Date:
11/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER, PIC
Authorized Official Telephone Number:
507-389-2483

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  200808 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2044574 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7773137 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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