1700895760 NPI number — MINNESOTA DRUG ACQUISITION CO LLC

Table of content: (NPI 1700895760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700895760 NPI number — MINNESOTA DRUG ACQUISITION CO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA DRUG ACQUISITION CO 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:
1700895760
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 EAST 2ND STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTHROP
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55396-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-647-5351
Provider Business Mailing Address Fax Number:
507-647-6445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 E 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTHROP
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-647-5351
Provider Business Practice Location Address Fax Number:
507-647-6445
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEAVENY
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
612-227-7811

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  263194 , 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: 631560700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2409387 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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