Provider Demographics
NPI:1508052424
Name:INTEGRATIAVECARE VADNAIS HEIGHTS LLC
Entity Type:Organization
Organization Name:INTEGRATIAVECARE VADNAIS HEIGHTS LLC
Other - Org Name:INTEGRATIVECARE NATURAL PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:651-489-2711
Mailing Address - Street 1:5 EAST COUNTY ROAD B
Mailing Address - Street 2:SUITE #2
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117
Mailing Address - Country:US
Mailing Address - Phone:651-489-2711
Mailing Address - Fax:651-287-1004
Practice Address - Street 1:5 EAST COUNTY ROAD B
Practice Address - Street 2:SUITE #2
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117
Practice Address - Country:US
Practice Address - Phone:651-489-2711
Practice Address - Fax:651-287-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262061-13336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy