Provider Demographics
NPI:1053471292
Name:ERICKSON DRUG INC
Entity Type:Organization
Organization Name:ERICKSON DRUG INC
Other - Org Name:BLOMBERG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND SEC TREAS
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZIOL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:952-469-2964
Mailing Address - Street 1:1583 HAMLINE AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2139
Mailing Address - Country:US
Mailing Address - Phone:651-646-9645
Mailing Address - Fax:651-632-2164
Practice Address - Street 1:1583 HAMLINE AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-2139
Practice Address - Country:US
Practice Address - Phone:651-646-9645
Practice Address - Fax:651-632-2164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2629023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2416368OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN327108000Medicaid