Provider Demographics
NPI:1275654725
Name:EAGLE DRUG OF ROCHESTER INC
Entity Type:Organization
Organization Name:EAGLE DRUG OF ROCHESTER INC
Other - Org Name:EAGLE DRUG OF ROCHESTER INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-289-3141
Mailing Address - Street 1:23 2ND ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-3017
Mailing Address - Country:US
Mailing Address - Phone:507-289-3141
Mailing Address - Fax:507-289-6848
Practice Address - Street 1:23 2ND ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-3017
Practice Address - Country:US
Practice Address - Phone:507-289-3141
Practice Address - Fax:507-289-6848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20123713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2407737OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN141757600Medicaid
2407737OtherNCPDP PROVIDER IDENTIFICATION NUMBER