Provider Demographics
NPI:1083758676
Name:HINCKLEY DRUG LLC
Entity Type:Organization
Organization Name:HINCKLEY DRUG LLC
Other - Org Name:HINCKLEY DRUG,LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-384-6166
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:HINCKLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55037-0130
Mailing Address - Country:US
Mailing Address - Phone:320-384-6166
Mailing Address - Fax:320-384-0016
Practice Address - Street 1:121 MAIN ST
Practice Address - Street 2:
Practice Address - City:HINCKLEY
Practice Address - State:MN
Practice Address - Zip Code:55037
Practice Address - Country:US
Practice Address - Phone:320-384-6166
Practice Address - Fax:320-384-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2635693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN690-727-000Medicaid
2127348OtherPK