Provider Demographics
NPI:1457832909
Name:BLACK FOREST PHARMACY SERVICES LTD
Entity Type:Organization
Organization Name:BLACK FOREST PHARMACY SERVICES LTD
Other - Org Name:GUIDEPOINT PHARMACY #101 LTC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCHWARTZWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-829-3476
Mailing Address - Street 1:14091 BAXTER DR STE 201B
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8835
Mailing Address - Country:US
Mailing Address - Phone:218-829-3476
Mailing Address - Fax:
Practice Address - Street 1:108 S 6TH ST STE 1
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3594
Practice Address - Country:US
Practice Address - Phone:218-829-0347
Practice Address - Fax:218-829-4701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2613733336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1407960875Medicaid