Provider Demographics
NPI:1073581302
Name:MINNESOTA STATE COLLEGES
Entity Type:Organization
Organization Name:MINNESOTA STATE COLLEGES
Other - Org Name:ST. CLOUD STATE UNIVERSITY HEALTH SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAF
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:320-308-4852
Mailing Address - Street 1:720 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4442
Mailing Address - Country:US
Mailing Address - Phone:320-308-4852
Mailing Address - Fax:320-308-4878
Practice Address - Street 1:251 6TH ST S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4491
Practice Address - Country:US
Practice Address - Phone:320-308-4852
Practice Address - Fax:320-308-4878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2008143336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045128OtherPK
MN492760500Medicaid