Provider Demographics
NPI:1265494777
Name:PARK NICOLLET HEALTH CARE PRODUCTS
Entity Type:Organization
Organization Name:PARK NICOLLET HEALTH CARE PRODUCTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:F
Authorized Official - Last Name:LENAGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-993-3108
Mailing Address - Street 1:3800 PARK NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14000 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5713
Practice Address - Country:US
Practice Address - Phone:952-993-8449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK NICOLLET HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-03
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
MN332S00000X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
No332S00000XSuppliersHearing Aid Equipment
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2412637OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN046098200Medicaid
MN21398500Medicaid
MN21398500Medicaid