1558704502 NPI number — FOSSTON LONG TERM CARE PHARMACY, INC

Table of content: DR. JORDAN LYNN PAULSEN DDS (NPI 1497315758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558704502 NPI number — FOSSTON LONG TERM CARE PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOSSTON LONG TERM CARE 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:
NORD'S LONG TERM CARE 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:
1558704502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 JOHNSON AVE N STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOSSTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56542-1327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-435-6646
Provider Business Mailing Address Fax Number:
218-435-1564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 JOHNSON AVE N STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOSSTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56542-1327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-435-6646
Provider Business Practice Location Address Fax Number:
218-435-1564
Provider Enumeration Date:
04/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FONDER
Authorized Official First Name:
RUTH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-435-6646

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  264082 , 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: 1558704502 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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