Provider Demographics
NPI:1578187456
Name:COBORNS INC
Entity Type:Organization
Organization Name:COBORNS INC
Other - Org Name:COBORN'S PHARMACY #2047
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:NELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:320-251-5505
Mailing Address - Street 1:PO BOX 6146
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-6146
Mailing Address - Country:US
Mailing Address - Phone:320-534-2745
Mailing Address - Fax:320-203-1095
Practice Address - Street 1:15700 88TH ST NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330
Practice Address - Country:US
Practice Address - Phone:763-328-1701
Practice Address - Fax:763-441-3072
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COBORNS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-05
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1578187456Medicaid
2434897OtherNCPDP
MN266193OtherSTATE LICENSE
FC9746908OtherDEA