Provider Demographics
NPI:1003858804
Name:GUARDIAN PHARMACY SVC LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY SVC LLC
Other - Org Name:GUARDIAN PHARMACY SERVICES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-351-4100
Mailing Address - Street 1:9703 VALLEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3508
Mailing Address - Country:US
Mailing Address - Phone:952-351-4100
Mailing Address - Fax:952-351-4102
Practice Address - Street 1:9703 VALLEY VIEW RD
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3508
Practice Address - Country:US
Practice Address - Phone:952-351-4100
Practice Address - Fax:952-351-4102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN26240153336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2425898OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN941422300Medicaid
5100870001Medicare NSC