Provider Demographics
NPI:1437457330
Name:THE DULUTH CLINIC, LTD
Entity Type:Organization
Organization Name:THE DULUTH CLINIC, LTD
Other - Org Name:ESSENTIA HEALTH SILVER BAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:99 EDISON BLVD
Mailing Address - Street 2:SUITE L
Mailing Address - City:SILVER BAY
Mailing Address - State:MN
Mailing Address - Zip Code:55614-1211
Mailing Address - Country:US
Mailing Address - Phone:218-226-3829
Mailing Address - Fax:218-226-3860
Practice Address - Street 1:99 EDISON BLVD
Practice Address - Street 2:SUITE L
Practice Address - City:SILVER BAY
Practice Address - State:MN
Practice Address - Zip Code:55614-1211
Practice Address - Country:US
Practice Address - Phone:218-226-3829
Practice Address - Fax:218-226-3860
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-02
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2636683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN573OtherTHE DULUTH CLINIC, LTD. CHAIN CODE
MN24-30700OtherNCPDP
MN1437457330Medicaid
MN24-30700OtherNCPDP