Provider Demographics
NPI:1225441157
Name:GRAND ITASCA CLINIC AND HOSPITAL
Entity Type:Organization
Organization Name:GRAND ITASCA CLINIC AND HOSPITAL
Other - Org Name:GRAND ITASCA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACDONELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-326-3401
Mailing Address - Street 1:1601 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-8648
Mailing Address - Country:US
Mailing Address - Phone:218-999-1885
Mailing Address - Fax:218-999-1887
Practice Address - Street 1:1601 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-8648
Practice Address - Country:US
Practice Address - Phone:218-999-1702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND ITASCA CLINIC AND HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-09
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN288995200Medicaid