Provider Demographics
NPI:1376848333
Name:NOVACEK HEALTHMART PHARMACY LLC
Entity Type:Organization
Organization Name:NOVACEK HEALTHMART PHARMACY LLC
Other - Org Name:NOVACEK HEALTHMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVACEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-469-0631
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:GREENBUSH
Mailing Address - State:MN
Mailing Address - Zip Code:56726-0278
Mailing Address - Country:US
Mailing Address - Phone:218-782-2221
Mailing Address - Fax:
Practice Address - Street 1:122 STATE HWY 11 E
Practice Address - Street 2:
Practice Address - City:GREENBUSH
Practice Address - State:MN
Practice Address - Zip Code:56726
Practice Address - Country:US
Practice Address - Phone:218-782-3456
Practice Address - Fax:218-782-3458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2636413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2430584OtherNCPDP PROVIDER IDENTIFICATION NUMBER