Basic Information
| Provider Information | |||||||||
| NPI: | 1487797544 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHERN ITASCA HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BIGFORK VALLEY PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 258 | ||||||||
| Address2: | 258 PINE TREE DRIVE | ||||||||
| City: | BIGFORK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566280258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187434444 | ||||||||
| FaxNumber: | 2187434232 | ||||||||
| Practice Location | |||||||||
| Address1: | 258 PINE TREE DRIVE | ||||||||
| Address2: | |||||||||
| City: | BIGFORK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566280258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187434444 | ||||||||
| FaxNumber: | 2187434232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 01/21/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BIBEAU | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | LEIGH | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 2187434444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHERN ITASCA HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | 261348 | MN | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336C0003X | 261348 | MN | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2613482 | 01 | MN | PHARMACY LICENSE | OTHER | BN4897053 | 01 | MN | DEA NUMBER | OTHER | 222121700 | 05 | MN | MEDICAID | 2421840 | 01 | MN | NCPDP | OTHER | 2613482 | 01 | MN | BOARD OF PHARMACY | OTHER |