Provider Demographics
NPI:1689602674
Name:BLOOMINGTON DRUG CO
Entity Type:Organization
Organization Name:BLOOMINGTON DRUG CO
Other - Org Name:BLOOMINGTON DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:952-884-7528
Mailing Address - Street 1:509 WEST 98TH STREET
Mailing Address - Street 2:BLOOMINGTON DRUG
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420
Mailing Address - Country:US
Mailing Address - Phone:952-884-7528
Mailing Address - Fax:952-884-6366
Practice Address - Street 1:509 WEST 98TH STREET
Practice Address - Street 2:BLOOMINGTON DRUG
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420
Practice Address - Country:US
Practice Address - Phone:952-884-7528
Practice Address - Fax:952-884-6366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20038723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN241357400Medicaid
2409438OtherNAPB
2409438OtherNAPB