Provider Demographics
NPI:1639477854
Name:FAIRVIEW PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:FAIRVIEW PHARMACY SERVICES LLC
Other - Org Name:FAIRVIEW PHARMACY PRIOR LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FASCHING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-617-3799
Mailing Address - Street 1:NW 7429
Mailing Address - Street 2:PO BOX 1450
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-7429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4151 WILLOWWOOD ST SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-4304
Practice Address - Country:US
Practice Address - Phone:952-447-9570
Practice Address - Fax:952-447-9571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0002X
MN2636973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2129459OtherPK
5274470038Medicare NSC