Provider Demographics
NPI:1659632743
Name:FAIRVIEW PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:FAIRVIEW PHARMACY SERVICES LLC
Other - Org Name:FAIRVIEW EDINA PHARMACY 340B
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:PO BOX 1450 NW 7429
Mailing Address - Street 2:
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 1:6401 FRANCE AVE S STE SL-1
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2104
Practice Address - Country:US
Practice Address - Phone:952-924-1400
Practice Address - Fax:952-924-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262528-9333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN002534801Medicaid