Provider Demographics
NPI:1629159736
Name:ERICKSON DRUG INC
Entity Type:Organization
Organization Name:ERICKSON DRUG INC
Other - Org Name:ERICKSON DRUG INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND SECRETARY TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZIOL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:952-469-2964
Mailing Address - Street 1:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-0808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20751 HOLYOKE AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9825
Practice Address - Country:US
Practice Address - Phone:952-469-2964
Practice Address - Fax:952-469-6753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2015-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
MN20041303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2044557OtherPK
MN7223201Medicaid
MN471357500Medicaid
2044557OtherPK