1689602674 NPI number — BLOOMINGTON DRUG CO

Table of content: (NPI 1689602674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689602674 NPI number — BLOOMINGTON DRUG CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMINGTON DRUG CO
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:
1689602674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
509 WEST 98TH STREET
Provider Second Line Business Mailing Address:
BLOOMINGTON DRUG
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-884-7528
Provider Business Mailing Address Fax Number:
952-884-6366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 WEST 98TH STREET
Provider Second Line Business Practice Location Address:
BLOOMINGTON DRUG
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-884-7528
Provider Business Practice Location Address Fax Number:
952-884-6366
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHAFFER
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT PIC
Authorized Official Telephone Number:
952-884-7528

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2003872 , 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: 241357400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2409438 . This is a "NAPB" identifier . This identifiers is of the category "OTHER".




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