Basic Information
| Provider Information | |||||||||
| NPI: | 1578128021 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST CLOUD HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTRACARE PHARMACY HEALTH PLAZA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1406 6TH AVENUE NORTH | ||||||||
| Address2: | |||||||||
| City: | ST. CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202294904 | ||||||||
| FaxNumber: | 3202295168 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIRCLE | ||||||||
| Address2: | SUITE 0550 | ||||||||
| City: | ST. CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202294930 | ||||||||
| FaxNumber: | 3206501778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2019 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUNKEL | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3202512700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336S0011X | Y | Suppliers | Pharmacy | Specialty Pharmacy |
No ID Information.