Provider Demographics
NPI:1225121668
Name:BREENS PHARMACY INC
Entity Type:Organization
Organization Name:BREENS PHARMACY INC
Other - Org Name:BREENS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VYKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:320-842-4221
Mailing Address - Street 1:1207 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:MN
Mailing Address - Zip Code:56215-1838
Mailing Address - Country:US
Mailing Address - Phone:320-842-4221
Mailing Address - Fax:320-842-5231
Practice Address - Street 1:1207 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:MN
Practice Address - Zip Code:56215-1838
Practice Address - Country:US
Practice Address - Phone:320-842-4221
Practice Address - Fax:320-842-5231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MN2056383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2044125OtherPK
MN492757500Medicaid
5127080001Medicare NSC