Provider Demographics
NPI:1316042260
Name:MAYO FOUNDATION FOR MEDICAL EDUCATION & RESEARCH
Entity Type:Organization
Organization Name:MAYO FOUNDATION FOR MEDICAL EDUCATION & RESEARCH
Other - Org Name:MAYO CLINIC PHARMACY NORTHWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:507-538-1680
Mailing Address - Street 1:PO BOX 083268
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60691-0268
Mailing Address - Country:US
Mailing Address - Phone:507-284-3390
Mailing Address - Fax:
Practice Address - Street 1:4111 WEST FRONTAGE RD HWY 52 NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-5919
Practice Address - Country:US
Practice Address - Phone:507-266-0966
Practice Address - Fax:507-538-1314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2615423336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2422563OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN054518000Medicaid