Provider Demographics
NPI:1417480633
Name:COBORNS INC
Entity Type:Organization
Organization Name:COBORNS INC
Other - Org Name:COBORN'S LTC PHARMACY #2006
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:320-534-2743
Mailing Address - Street 1:PO BOX 6146
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-6146
Mailing Address - Country:US
Mailing Address - Phone:320-534-2745
Mailing Address - Fax:320-203-1095
Practice Address - Street 1:1105 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-2943
Practice Address - Country:US
Practice Address - Phone:320-632-2380
Practice Address - Fax:320-632-3079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COBORNS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-05
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2434760OtherNCPDP LTC
MN261254OtherPHARMACY LICENSE
1417480633OtherNPI LTC
MN1760555304Medicaid
MN1417480633Medicaid
MNBC4361503OtherDEA