Provider Demographics
NPI:1639474612
Name:WHITE BEAR HEALTH MART PHARMACY LLC
Entity Type:Organization
Organization Name:WHITE BEAR HEALTH MART PHARMACY LLC
Other - Org Name:WHITE BEAR HEALTH MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:JORGENSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:651-289-4300
Mailing Address - Street 1:2008 COUNTY ROAD E E
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7333
Mailing Address - Country:US
Mailing Address - Phone:651-289-4300
Mailing Address - Fax:651-289-4301
Practice Address - Street 1:2008 COUNTY ROAD E E
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-7333
Practice Address - Country:US
Practice Address - Phone:651-289-4300
Practice Address - Fax:651-289-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center