Provider Demographics
NPI:1487839189
Name:FAIRVIEW PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:FAIRVIEW PHARMACY SERVICES LLC
Other - Org Name:FAIRVIEW ANDOVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FASCHING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-617-3799
Mailing Address - Street 1:NW 7429
Mailing Address - Street 2:PO BOX 1450
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-7429
Mailing Address - Country:US
Mailing Address - Phone:612-617-3812
Mailing Address - Fax:612-672-6545
Practice Address - Street 1:13819 HANSON BLVD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-7608
Practice Address - Country:US
Practice Address - Phone:763-862-4445
Practice Address - Fax:763-862-4462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2631153336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1487839189Medicaid
2049348OtherPK
5274470033Medicare NSC