Provider Demographics
NPI:1164653317
Name:MINNESOTA DRUG ACQUISITION CO LLC
Entity Type:Organization
Organization Name:MINNESOTA DRUG ACQUISITION CO LLC
Other - Org Name:KEAVENY LTC PHARMACY #210
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PREIDENT
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:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:COKATO
Mailing Address - State:MN
Mailing Address - Zip Code:55321-0550
Mailing Address - Country:US
Mailing Address - Phone:320-286-5129
Mailing Address - Fax:320-286-5434
Practice Address - Street 1:201 BROADWAY AVE S
Practice Address - Street 2:
Practice Address - City:COKATO
Practice Address - State:MN
Practice Address - Zip Code:55321-4681
Practice Address - Country:US
Practice Address - Phone:320-286-5129
Practice Address - Fax:320-286-5434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2634303336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2429858OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN116453317Medicaid
MN116453317Medicaid