Provider Demographics
NPI:1114344215
Name:OMC RETAIL SERVICES LLC
Entity Type:Organization
Organization Name:OMC RETAIL SERVICES LLC
Other - Org Name:OLMSTED MEDICAL CENTER SE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DORNACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-292-7255
Mailing Address - Street 1:210 9TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-6756
Mailing Address - Country:US
Mailing Address - Phone:507-535-1974
Mailing Address - Fax:507-281-7974
Practice Address - Street 1:210 9TH ST SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-6756
Practice Address - Country:US
Practice Address - Phone:507-535-1974
Practice Address - Fax:507-281-7974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1114344215Medicaid
7567960002Medicare NSC