1053401984 NPI number — THRIFTY DRUG STORES INC

Table of content: MRS. NICOLE MARIE VILLANUEVA MSW, LMSW (NPI 1457479347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053401984 NPI number — THRIFTY DRUG STORES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THRIFTY DRUG STORES 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:
Provider Other Organization Name Type Code:
6
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:
1053401984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6701 EVENSTAD DR N STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55369-6013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-513-4300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 INTERNATIONAL DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
RED LAKE FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56750-4665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-253-3480
Provider Business Practice Location Address Fax Number:
877-201-5330
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEIPPERT
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
763-585-3507

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 261880 , 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: 1053401984 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1456142 RX , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2048155 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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