Basic Information
Provider Information | |||||||||
NPI: | 1316901333 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLINA HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALLINA HEALTH HEART HOSPITAL PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2925 CHICAGO AVE # MR 10860 | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6122621166 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 920 E 28TH ST | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071139 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6127753100 | ||||||||
FaxNumber: | 6127753150 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2006 | ||||||||
LastUpdateDate: | 05/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BYRE | ||||||||
AuthorizedOfficialFirstName: | ANN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6122625992 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X |   |   | N |   | Suppliers | Pharmacy | Clinic Pharmacy | 3336L0003X |   |   | N |   | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336S0011X | 2625878 | MN | N |   | Suppliers | Pharmacy | Specialty Pharmacy | 3336C0003X |   |   | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2426749 | 01 |   | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 158478200 | 05 | MN |   | MEDICAID | 2426749 | 01 |   | OTHER ID NUMBER | OTHER |