Provider Demographics
NPI:1497929558
Name:COUNTRY MANOR CAMPUS LLC
Entity Type:Organization
Organization Name:COUNTRY MANOR CAMPUS LLC
Other - Org Name:COUNTRY MANOR LTC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-255-0801
Mailing Address - Street 1:520 1ST ST NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-1274
Mailing Address - Country:US
Mailing Address - Phone:320-255-0801
Mailing Address - Fax:320-230-3825
Practice Address - Street 1:520 1ST ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-1274
Practice Address - Country:US
Practice Address - Phone:320-255-0801
Practice Address - Fax:320-230-3825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MN2628823336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125115OtherPK