Provider Demographics
NPI:1093883605
Name:MINNESOTA DRUG ACQUISITION CO LLC
Entity Type:Organization
Organization Name:MINNESOTA DRUG ACQUISITION CO LLC
Other - Org Name:WOLFF DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KEAVENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-227-7811
Mailing Address - Street 1:7645 E 63RD ST
Mailing Address - Street 2:STE 105
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-1208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 MAIN ST
Practice Address - Street 2:
Practice Address - City:PIERZ
Practice Address - State:MN
Practice Address - Zip Code:56364
Practice Address - Country:US
Practice Address - Phone:320-468-6482
Practice Address - Fax:320-468-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2633203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2418158OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN526058200Medicaid
6255420002Medicare NSC