Basic Information
| Provider Information | |||||||||
| NPI: | 1316042260 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYO FOUNDATION FOR MEDICAL EDUCATION & RESEARCH | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAYO CLINIC PHARMACY NORTHWEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 083268 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606910268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072843390 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4111 WEST FRONTAGE RD HWY 52 NW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559015919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072660966 | ||||||||
| FaxNumber: | 5075381314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SWANSON | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5075381680 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 261542 | MN | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2422563 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |