Provider Demographics
NPI:1003114539
Name:THE DULUTH CLINIC, LTD
Entity Type:Organization
Organization Name:THE DULUTH CLINIC, LTD
Other - Org Name:ESSENTIA HEALTH LAKEWALK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:1502 LONDON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-1788
Mailing Address - Country:US
Mailing Address - Phone:218-786-3563
Mailing Address - Fax:
Practice Address - Street 1:1502 LONDON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-1788
Practice Address - Country:US
Practice Address - Phone:218-733-1110
Practice Address - Fax:218-733-1112
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-08
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2636673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1003114539Medicaid
MN2430712OtherNCPDP
MN573OtherTHE DULUTH CLINIC, LTD. CHAIN CODE
MN1003114539Medicaid