Basic Information
| Provider Information | |||||||||
| NPI: | 1750947040 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRVIEW PHARMACY SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UMP PHALEN CLINIC MTM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 KASOTA AVE SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554142842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126725128 | ||||||||
| FaxNumber: | 6126727320 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 MARYLAND AVE E | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551062824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517723461 | ||||||||
| FaxNumber: | 6517722605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2019 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | BEACHER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6126173812 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.