1568732709 NPI number — GUARDIAN PHARMACY OF MINNESOTA LLC

Table of content: (NPI 1568732709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568732709 NPI number — GUARDIAN PHARMACY OF MINNESOTA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF MINNESOTA 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:
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:
1568732709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT # 2410 GUARDIAN PHARMACY OF MINNESOTA
Provider Second Line Business Mailing Address:
P.O. BOX 11407
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-810-0089
Provider Business Mailing Address Fax Number:
404-810-0094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
940 INDUSTRIAL DR S
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SAUK RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56379-1271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-230-1050
Provider Business Practice Location Address Fax Number:
320-230-1051
Provider Enumeration Date:
01/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BOE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
320-257-8758

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 263805 , 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: 1568732709 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2132903 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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