Provider Demographics
NPI:1578635363
Name:CEDERSTROM PHARMACY INC
Entity Type:Organization
Organization Name:CEDERSTROM PHARMACY INC
Other - Org Name:CEDERSTROM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CEDERTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-235-7803
Mailing Address - Street 1:1004 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004 1ST ST S
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3510
Practice Address - Country:US
Practice Address - Phone:320-235-7803
Practice Address - Fax:320-235-7807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2609503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN972860100Medicaid
2418312OtherOTHER ID NUMBER
0406420001Medicare NSC