Provider Demographics
NPI:1477668580
Name:THE DULUTH CLINIC, LTD.
Entity Type:Organization
Organization Name:THE DULUTH CLINIC, LTD.
Other - Org Name:ESSENTIA HEALTH DULUTH 1ST STREET 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 1:420 E 1ST STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1901
Mailing Address - Country:US
Mailing Address - Phone:218-786-1685
Mailing Address - Fax:218-786-1699
Practice Address - Street 1:420 E 1ST STREET
Practice Address - Street 2:SUITE A
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1901
Practice Address - Country:US
Practice Address - Phone:218-786-1685
Practice Address - Fax:218-786-1699
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-20
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26269323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24-27448OtherNCPDP
MN573OtherTHE DULUTH CLINIC, LTD CHAIN CODE
MN779427400Medicaid
MN24-27448OtherNCPDP