Provider Demographics
NPI:1346244274
Name:GOODRICH PHARMACY INC
Entity Type:Organization
Organization Name:GOODRICH PHARMACY INC
Other - Org Name:GOODRICH PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SIMENSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:763-421-5540
Mailing Address - Street 1:2621 GREENHAVEN RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-5566
Mailing Address - Country:US
Mailing Address - Phone:763-421-5540
Mailing Address - Fax:763-421-9229
Practice Address - Street 1:2621 GREENHAVEN RD STE 1
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-5566
Practice Address - Country:US
Practice Address - Phone:763-421-5540
Practice Address - Fax:763-421-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNZ008330333600000X
3336C0003X, 3336C0004X
MN2650823336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
24D0914028OtherCLIA
MN571358700Medicaid
0548820001OtherPTAN
MN0548820001Medicare NSC