Provider Demographics
NPI:1326054727
Name:MAYO CLINIC HEALTH SYSTEM - PHARMACY & HOME MEDICAL INC
Entity Type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM - PHARMACY & HOME MEDICAL INC
Other - Org Name:MAYO CLINIC STORE - MIDELFORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-838-5270
Mailing Address - Street 1:21 1ST ST SW STE 1-18
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-3124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 BELLINGER ST.
Practice Address - Street 2:SUITE PHM #3
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-5222
Practice Address - Country:US
Practice Address - Phone:715-838-1815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYO CLINIC HEALTH SYSTEM - PHARMACY & HOME MEDICAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-31
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6005332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33094500Medicaid
51 03027OtherNCPDP
AL8319988OtherDEA
WI0408270001Medicare NSC