Provider Demographics
NPI:1497832364
Name:GREEN LAKE THRIFTY WHITE DRUG INC
Entity Type:Organization
Organization Name:GREEN LAKE THRIFTY WHITE DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MERTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-796-2103
Mailing Address - Street 1:300 HIGHWAY 23 STE 4
Mailing Address - Street 2:
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288-9677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 HIGHWAY 23 STE 4
Practice Address - Street 2:
Practice Address - City:SPICER
Practice Address - State:MN
Practice Address - Zip Code:56288-9677
Practice Address - Country:US
Practice Address - Phone:320-796-2103
Practice Address - Fax:320-796-4060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2616447333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2418881OtherOTHER ID NUMBER-COMMERCIAL NUMBER