Basic Information
| Provider Information | |||||||||
| NPI: | 1487839189 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW PHARMACY SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAIRVIEW ANDOVER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | NW 7429 | ||||||||
| Address2: | PO BOX 1450 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554857429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126173812 | ||||||||
| FaxNumber: | 6126726545 | ||||||||
| Practice Location | |||||||||
| Address1: | 13819 HANSON BLVD NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ANDOVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553047608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7638624445 | ||||||||
| FaxNumber: | 7638624462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | BATSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | HAYES | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6126173812 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 263115 | MN | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1487839189 | 05 | MN | MEDICAID | 2049348 | 01 | PK | OTHER |