Provider Demographics
NPI:1417979063
Name:TARGET CORPORATION AND SUBSIDIARIES
Entity Type:Organization
Organization Name:TARGET CORPORATION AND SUBSIDIARIES
Other - Org Name:TARGET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE ADMIN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:PACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-696-2268
Mailing Address - Street 1:1000 NICOLLET MALL # 0910
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7501 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-6665
Practice Address - Country:US
Practice Address - Phone:407-822-5215
Practice Address - Fax:407-822-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
FLPH179833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1092890OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL022855900Medicaid
0640710518Medicare NSC