Provider Demographics
NPI:1063659183
Name:CHILDREN'S HEALTH CARE
Entity Type:Organization
Organization Name:CHILDREN'S HEALTH CARE
Other - Org Name:CHILDREN'S HOSPTIALS AND CLINICS OF MN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OUTPATIENT PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHESTEVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-813-7290
Mailing Address - Street 1:PO BOX 860123
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0112
Mailing Address - Country:US
Mailing Address - Phone:612-813-7290
Mailing Address - Fax:612-813-7296
Practice Address - Street 1:2530 CHICAGO AVE
Practice Address - Street 2:CSC 225
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4289
Practice Address - Country:US
Practice Address - Phone:612-813-7290
Practice Address - Fax:612-813-7296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MN2633753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120511OtherPK
MN137647000Medicaid