Provider Demographics
NPI:1528222940
Name:CCS PHARMACY
Entity Type:Organization
Organization Name:CCS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PACULT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:651-894-4785
Mailing Address - Street 1:4203 WEBBER PKWY
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-1747
Mailing Address - Country:US
Mailing Address - Phone:612-251-8578
Mailing Address - Fax:
Practice Address - Street 1:4203 WEBBER PKWY
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-1747
Practice Address - Country:US
Practice Address - Phone:612-251-8578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2632213336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy