Basic Information
| Provider Information | |||||||||
| NPI: | 1326148271 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA PARK MEDICAL GROUP, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CPMG-COLUMBIA PARK PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6401 UNIVERSITY AVE NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554324341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7635713008 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 CENTRAL AVE NE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554212968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7637828100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEIR | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | LOUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7635865877 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 261734-9 | MN | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 02991CO | 01 | MN | BCBS DME NUMBER | OTHER | 23953 | 01 | MN | ANDA # | OTHER | 24-23387 | 01 | MN | NABP | OTHER | BC6494772 | 01 | MN | PHARMACY DEA # | OTHER | 10039288 | 01 | MN | IPC NUMBER | OTHER | 895065 | 01 | MN | MCKESSON | OTHER |