Provider Demographics
NPI:1619903994
Name:ROLSETH DRUG CO
Entity Type:Organization
Organization Name:ROLSETH DRUG CO
Other - Org Name:WYOMING DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-462-2082
Mailing Address - Street 1:26710 FOREST BLVD
Mailing Address - Street 2:PO BOX 584
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8022
Mailing Address - Country:US
Mailing Address - Phone:651-462-2082
Mailing Address - Fax:
Practice Address - Street 1:26710 FOREST BLVD
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8022
Practice Address - Country:US
Practice Address - Phone:651-462-2082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2056641332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN183257300Medicaid