Provider Demographics
NPI:1659486769
Name:THE DULUTH CLINIC, LTD
Entity Type:Organization
Organization Name:THE DULUTH CLINIC, LTD
Other - Org Name:ESSENTIA HEALTH VIRGINIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:1101 9TH ST N
Mailing Address - Street 2:SUITE A
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2329
Mailing Address - Country:US
Mailing Address - Phone:218-749-7828
Mailing Address - Fax:218-749-7962
Practice Address - Street 1:1101 9TH ST N
Practice Address - Street 2:SUITE A
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2329
Practice Address - Country:US
Practice Address - Phone:218-749-7828
Practice Address - Fax:218-749-7962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-20
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20451443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24-22688OtherNCPDP
MN573OtherTHE DULUTH CLINIC, LTD CHAIN CODE
MN194812100Medicaid
MN0440980002Medicare NSC