Provider Demographics
NPI:1558397232
Name:CLEARWATER CNTY MEM HOSP PHCY
Entity Type:Organization
Organization Name:CLEARWATER CNTY MEM HOSP PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMASIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-694-6501
Mailing Address - Street 1:203 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621-8305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 4TH ST NW
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621-8305
Practice Address - Country:US
Practice Address - Phone:218-694-6501
Practice Address - Fax:218-694-2185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2057721333600000X
3336I0012X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336I0012XSuppliersPharmacyInstitutional Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2414681OtherOTHER ID NUMBER-COMMERCIAL NUMBER
241328Medicare ID - Type Unspecified