Provider Demographics
NPI:1154467678
Name:PERHAM HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:PERHAM HOSPITAL DISTRICT
Other - Org Name:PERHAM HEALTH HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-347-1571
Mailing Address - Street 1:1000 CONEY ST W
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-2102
Mailing Address - Country:US
Mailing Address - Phone:218-347-1580
Mailing Address - Fax:218-347-1652
Practice Address - Street 1:1000 CONEY ST W
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2102
Practice Address - Country:US
Practice Address - Phone:218-347-1580
Practice Address - Fax:218-347-1652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MN2003033336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045652OtherPK
MN211047400Medicaid