Provider Demographics
NPI:1265453237
Name:CARLSON DRUG INC
Entity Type:Organization
Organization Name:CARLSON DRUG INC
Other - Org Name:CARLSON DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-839-6102
Mailing Address - Street 1:147 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1408
Mailing Address - Country:US
Mailing Address - Phone:320-839-6102
Mailing Address - Fax:320-839-3985
Practice Address - Street 1:147 2ND ST NW
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1408
Practice Address - Country:US
Practice Address - Phone:320-839-6102
Practice Address - Fax:320-839-3985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MN2621453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045042OtherPK
MN350511100Medicaid
SD8530150Medicaid
MN350511100Medicaid