Provider Demographics
NPI:1033458922
Name:MINNESOTA INDEPENDENT COOPERATIVE
Entity Type:Organization
Organization Name:MINNESOTA INDEPENDENT COOPERATIVE
Other - Org Name:DIABETIC CARE INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-686-5011
Mailing Address - Street 1:2980 COMMERS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2370
Mailing Address - Country:US
Mailing Address - Phone:800-940-1934
Mailing Address - Fax:
Practice Address - Street 1:2980 COMMERS DR STE 200
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-2370
Practice Address - Country:US
Practice Address - Phone:800-940-1934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MN3616873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy