Provider Demographics
NPI:1003289257
Name:FAIRVIEW PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:FAIRVIEW PHARMACY SERVICES LLC
Other - Org Name:FAIRVIEW PHARMACY BURNSVILLE SCC 340B
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FASCHING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-617-3799
Mailing Address - Street 1:14101 FAIRVIEW DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4590
Mailing Address - Country:US
Mailing Address - Phone:952-405-5630
Mailing Address - Fax:952-405-5631
Practice Address - Street 1:14101 FAIRVIEW DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4590
Practice Address - Country:US
Practice Address - Phone:952-405-5630
Practice Address - Fax:952-405-5631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1851792469Medicaid