Provider Demographics
NPI:1619089612
Name:GOODRICH PHARMACY INC
Entity Type:Organization
Organization Name:GOODRICH PHARMACY INC
Other - Org Name:GOODRICH PHARMACY ANDOVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT.
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-434-1901
Mailing Address - Street 1:2621 GREENHAVEN RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-5566
Mailing Address - Country:US
Mailing Address - Phone:763-421-4766
Mailing Address - Fax:763-421-9229
Practice Address - Street 1:15245 BLUEBIRD ST NW
Practice Address - Street 2:STE B
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304
Practice Address - Country:US
Practice Address - Phone:763-434-1901
Practice Address - Fax:763-587-4694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2650793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2047848OtherPK
MN781019900Medicaid