Basic Information
Provider Information | |||||||||
NPI: | 1356501621 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAIRVIEW PHARMACY SERVICES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAIRVIEW NEW BRIGHTON 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: | 1151 SILVER LAKE RD NW | ||||||||
Address2: |   | ||||||||
City: | NEW BRIGHTON | ||||||||
State: | MN | ||||||||
PostalCode: | 551126324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6517462580 | ||||||||
FaxNumber: | 6517462588 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2008 | ||||||||
LastUpdateDate: | 08/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEACHER | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6126725139 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 263185 | MN | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2049509 | 01 |   | PK | OTHER | 1356501621 | 05 | MN |   | MEDICAID |