Provider Demographics
NPI:1003937582
Name:ST THERESE HOME INC
Entity Type:Organization
Organization Name:ST THERESE HOME INC
Other - Org Name:ST THERESE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:763-531-5005
Mailing Address - Street 1:8000 BASS LAKE RD
Mailing Address - Street 2:#200A
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3118
Mailing Address - Country:US
Mailing Address - Phone:763-531-5005
Mailing Address - Fax:763-531-5061
Practice Address - Street 1:8000 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3118
Practice Address - Country:US
Practice Address - Phone:763-531-5005
Practice Address - Fax:763-531-5061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MN2005113336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045739OtherPK
MN712242001Medicaid
1000350001Medicare NSC