Basic Information
| Provider Information | |||||||||
| NPI: | 1366953507 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW PHARMACY SERVICES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | HEALTHEAST PHARMACY - ST. PAUL 340B | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | NW 7429 | ||||||||
| Address2: | PO BOX 1450 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554857429 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 17 EXCHANGE ST W STE 150 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551021045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513264505 | ||||||||
| FaxNumber: | 6123650382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2017 | ||||||||
| LastUpdateDate: | 10/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | BEACHER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6126725139 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 333600000X | Y | Suppliers | Pharmacy |
No ID Information.