Provider Demographics
NPI:1063444057
Name:FAIRVIEW PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:FAIRVIEW PHARMACY SERVICES LLC
Other - Org Name:FAIRVIEW CEDAR RIDGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FASCHING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-617-3799
Mailing Address - Street 1:NW 7429
Mailing Address - Street 2:PO BOX 1450
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-7429
Mailing Address - Country:US
Mailing Address - Phone:612-672-5139
Mailing Address - Fax:612-672-6545
Practice Address - Street 1:15650 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7283
Practice Address - Country:US
Practice Address - Phone:952-997-4155
Practice Address - Fax:952-997-4156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0002X
MN2625243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN984645000Medicaid
2048491OtherPK
MN1063444057Medicaid
5274470012Medicare NSC