1003947060 NPI number — SIVERSON PHARMACY AND GIFTS LLC

Table of content: (NPI 1003947060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003947060 NPI number — SIVERSON PHARMACY AND GIFTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIVERSON PHARMACY AND GIFTS 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:
Provider Other Organization Name Type Code:
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:
1003947060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 SOUTH MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 65
Provider Business Mailing Address City Name:
HENDRICKS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56136-0065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-275-3323
Provider Business Mailing Address Fax Number:
507-275-3810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 SOUTH MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDRICKS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56136-1230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-275-3323
Provider Business Practice Location Address Fax Number:
507-275-3810
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SIVERSON
Authorized Official First Name:
SLADE
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
OWNER/CHIEF PHARMACIST
Authorized Official Telephone Number:
507-275-3323

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  9491302 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 482257900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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