Provider Demographics
NPI:1093771818
Name:ST. CLOUD HOSPITAL
Entity Type:Organization
Organization Name:ST. CLOUD HOSPITAL
Other - Org Name:CENTRACARE PHARMACY AT ST CLOUD HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:P
Authorized Official - Last Name:KUNKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-251-2710
Mailing Address - Street 1:1406 SIXTH AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-255-5670
Mailing Address - Fax:320-255-5793
Practice Address - Street 1:1406 SIXTH AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-255-5670
Practice Address - Fax:320-255-5793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26192793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2423894OtherNCPDP
MN400640200Medicaid
0968910002Medicare NSC