Provider Demographics
NPI:1194849687
Name:COUNTY VALU PHARMACY
Entity Type:Organization
Organization Name:COUNTY VALU PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:651-674-7177
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:6445 MAIN STREET
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056
Mailing Address - Country:US
Mailing Address - Phone:651-674-7177
Mailing Address - Fax:651-277-0089
Practice Address - Street 1:6445 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056
Practice Address - Country:US
Practice Address - Phone:651-674-7177
Practice Address - Fax:651-277-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2603311333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2415645Medicare UPIN
MN0891420001Medicare ID - Type Unspecified