Provider Demographics
NPI:1114060886
Name:DRUG EXPRESS PHARMACIES INC
Entity Type:Organization
Organization Name:DRUG EXPRESS PHARMACIES INC
Other - Org Name:DRUG EXPRESS AND VARIETY GALORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:952-873-6220
Mailing Address - Street 1:1101 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:NEW PRAGUE
Mailing Address - State:MN
Mailing Address - Zip Code:56071-2197
Mailing Address - Country:US
Mailing Address - Phone:952-758-5262
Mailing Address - Fax:952-758-5646
Practice Address - Street 1:1101 1ST ST NE
Practice Address - Street 2:
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071-2197
Practice Address - Country:US
Practice Address - Phone:952-758-5262
Practice Address - Fax:952-758-5646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2609743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2420519OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN099760900Medicaid