Provider Demographics
NPI:1003947060
Name:SIVERSON PHARMACY AND GIFTS LLC
Entity Type:Organization
Organization Name:SIVERSON PHARMACY AND GIFTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SLADE
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:SIVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:507-275-3323
Mailing Address - Street 1:118 SOUTH MAIN ST
Mailing Address - Street 2:PO BOX 65
Mailing Address - City:HENDRICKS
Mailing Address - State:MN
Mailing Address - Zip Code:56136-0065
Mailing Address - Country:US
Mailing Address - Phone:507-275-3323
Mailing Address - Fax:507-275-3810
Practice Address - Street 1:118 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDRICKS
Practice Address - State:MN
Practice Address - Zip Code:56136-1230
Practice Address - Country:US
Practice Address - Phone:507-275-3323
Practice Address - Fax:507-275-3810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9491302333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN482257900Medicaid
MN6364770001Medicare NSC