Provider Demographics
NPI:1346383908
Name:MATTSON PHARMACY, INC
Entity Type:Organization
Organization Name:MATTSON PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DESROSIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-463-2465
Mailing Address - Street 1:111 MAIN AVE S
Mailing Address - Street 2:
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751-1421
Mailing Address - Country:US
Mailing Address - Phone:218-463-2465
Mailing Address - Fax:218-463-2875
Practice Address - Street 1:111 MAIN AVE S
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1421
Practice Address - Country:US
Practice Address - Phone:218-463-2465
Practice Address - Fax:218-463-2875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0683560001332B00000X
MN2011903336C0003X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN981858800Medicaid
MN2011903OtherPHARMACY LICENSE
MN2407802OtherNCPDP NUMBER
MN2407802OtherNCPDP NUMBER
MNAM7913761OtherDEA REGISTRATION NUMBER