Provider Demographics
NPI:1366859936
Name:PARK NICOLLET HEALTH CARE PRODUCTS
Entity Type:Organization
Organization Name:PARK NICOLLET HEALTH CARE PRODUCTS
Other - Org Name:PARK NICOLLET PHARMACY TRIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-967-5049
Mailing Address - Street 1:700 5TH ST S
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7764
Mailing Address - Country:US
Mailing Address - Phone:952-993-3804
Mailing Address - Fax:952-993-1503
Practice Address - Street 1:8100 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4800
Practice Address - Country:US
Practice Address - Phone:952-977-0470
Practice Address - Fax:952-977-0471
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK NICOLLET PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-16
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336C0004X
MN2644973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1366859936Medicaid
2146852OtherPK