Provider Demographics
NPI:1407931553
Name:WACONIA PHARMACY
Entity Type:Organization
Organization Name:WACONIA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSDEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:952-442-3274
Mailing Address - Street 1:430 HIGHWAY 5 WEST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1795
Mailing Address - Country:US
Mailing Address - Phone:952-442-3274
Mailing Address - Fax:952-442-3284
Practice Address - Street 1:430 HIGHWAY 5 WEST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1795
Practice Address - Country:US
Practice Address - Phone:952-442-3274
Practice Address - Fax:952-442-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262330-43336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1273980002Medicare ID - Type Unspecified