Provider Demographics
NPI:1093850844
Name:COOK HOSPITAL PHARMACY
Entity Type:Organization
Organization Name:COOK HOSPITAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LJOSENVOOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:218-666-6229
Mailing Address - Street 1:10 5TH ST SE
Mailing Address - Street 2:
Mailing Address - City:COOK
Mailing Address - State:MN
Mailing Address - Zip Code:55723-9702
Mailing Address - Country:US
Mailing Address - Phone:218-666-6229
Mailing Address - Fax:218-666-6249
Practice Address - Street 1:10 5TH ST SE
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:MN
Practice Address - Zip Code:55723-9702
Practice Address - Country:US
Practice Address - Phone:218-666-6229
Practice Address - Fax:218-666-6249
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN260751-1333600000X
3336C0003X, 3336I0012X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN752547800Medicaid
MN2418716OtherNCPDP