Provider Demographics
NPI:1073544151
Name:FAMILY HEALTH SYSTEMS OF MOOSE LAKE INC
Entity Type:Organization
Organization Name:FAMILY HEALTH SYSTEMS OF MOOSE LAKE INC
Other - Org Name:FAMILY PHARMACY SANDSTONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:STORCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-485-5671
Mailing Address - Street 1:710 S KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767
Mailing Address - Country:US
Mailing Address - Phone:218-485-5671
Mailing Address - Fax:
Practice Address - Street 1:204 LUNDORFF DR
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-5051
Practice Address - Country:US
Practice Address - Phone:320-245-5500
Practice Address - Fax:320-245-5123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
MN26149023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0002XSuppliersPharmacyClinic Pharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2718900Medicaid