Basic Information
Provider Information | |||||||||
NPI: | 1588918049 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAYO FOUNDATION FOR MEDICAL EDUCATION & RESEARCH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MAYO CLINIC PHARMACY-RED WING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 083268 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606910268 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5072843390 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 701 HEWITT BLVD | ||||||||
Address2: | SUITE 2116 | ||||||||
City: | RED WING | ||||||||
State: | MN | ||||||||
PostalCode: | 55066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512675785 | ||||||||
FaxNumber: | 6512675985 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2012 | ||||||||
LastUpdateDate: | 10/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SWANSON | ||||||||
AuthorizedOfficialFirstName: | ANDREA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5075381680 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 263981 | MN | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | FM3555678 | 01 |   | DEA REGISTRATION | OTHER | 2431714 | 01 |   | NCPDP | OTHER | 263981 | 01 | MN | PHARMACY LICENSE | OTHER |