Basic Information
| Provider Information | |||||||||
| NPI: | 1548222953 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK NICOLLET HEALTH CARE PRODUCTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 PARK NICOLLET BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554162527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529931000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15800 95TH AVE N | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553694400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529931440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 10/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | LENAGH | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9529933108 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARK NICOLLET HEALTH SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 3336C0002X | 263381 | MN | N | Suppliers | Pharmacy | Clinic Pharmacy | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 2429733 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 21398500 | 05 | MN | MEDICAID |