Provider Demographics
NPI:1417056698
Name:COLUMBIA PARK MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:COLUMBIA PARK MEDICAL GROUP, PA
Other - Org Name:CPMG-ANDOVER PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:WEIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-586-5877
Mailing Address - Street 1:6401 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4341
Mailing Address - Country:US
Mailing Address - Phone:763-572-5710
Mailing Address - Fax:763-571-3008
Practice Address - Street 1:13819 HANSON BLVD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-7608
Practice Address - Country:US
Practice Address - Phone:763-862-4445
Practice Address - Fax:763-862-4465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261566-83336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN306066OtherANDA
MN45Q12COOtherBCBS DME NUMBER
MN10016952OtherIPC NUMBER
MN24-22917OtherNABP NUMBER
MN314420OtherMCKESSON
MN314420OtherMCKESSON