Basic Information
Provider Information | |||||||||
NPI: | 1063444057 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAIRVIEW PHARMACY SERVICES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAIRVIEW CEDAR RIDGE PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | NW 7429 | ||||||||
Address2: | PO BOX 1450 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554857429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6126725139 | ||||||||
FaxNumber: | 6126726545 | ||||||||
Practice Location | |||||||||
Address1: | 15650 CEDAR AVE | ||||||||
Address2: |   | ||||||||
City: | APPLE VALLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 551247283 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529974155 | ||||||||
FaxNumber: | 9529974156 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 08/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEACHER | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6126725139 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 3336C0002X |   |   | N |   | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | 262524 | MN | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 984645000 | 05 | MN |   | MEDICAID | 2048491 | 01 |   | PK | OTHER | 1063444057 | 05 | MN |   | MEDICAID |