1952431884 NPI number — PRAIRIESTONE PHARMACY LLC

Table of content: (NPI 1952431884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952431884 NPI number — PRAIRIESTONE PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIESTONE PHARMACY 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:
1952431884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9830
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84109-9830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-973-1955
Provider Business Mailing Address Fax Number:
317-575-6195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9995 W 69TH ST
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
EDEN PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55344-3457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-656-5095
Provider Business Practice Location Address Fax Number:
952-656-5096
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MIDDENDORF
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO, SECRETARY, TREASURER
Authorized Official Telephone Number:
317-569-8234

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  262983 , 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: 778630000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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