Provider Demographics
NPI:1558704502
Name:FOSSTON LONG TERM CARE PHARMACY, INC
Entity Type:Organization
Organization Name:FOSSTON LONG TERM CARE PHARMACY, INC
Other - Org Name:NORD'S LONG TERM CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:FONDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:218-435-6646
Mailing Address - Street 1:115 JOHNSON AVE N STE A
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-1327
Mailing Address - Country:US
Mailing Address - Phone:218-435-6646
Mailing Address - Fax:218-435-1564
Practice Address - Street 1:115 JOHNSON AVE N STE A
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1327
Practice Address - Country:US
Practice Address - Phone:218-435-6646
Practice Address - Fax:218-435-1564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2640823336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1558704502Medicaid