Basic Information
| Provider Information | |||||||||
| NPI: | 1013966175 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CLOUD HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CENTRACARE PHARMACY HEALTH PLAZA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIRCLE | ||||||||
| Address2: | SUITE 1350 | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202294904 | ||||||||
| FaxNumber: | 3202295168 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIRCLE | ||||||||
| Address2: | SUITE 1350 | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202294904 | ||||||||
| FaxNumber: | 3202295168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUNKEL | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3202512700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 2620682 | MN | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2424543 | 01 | NCPDP | OTHER | 05092Y800 | 05 | MN | MEDICAID |