Provider Demographics
NPI:1730110115
Name:ST MARY'S INNOVIS HEALTH
Entity Type:Organization
Organization Name:ST MARY'S INNOVIS HEALTH
Other - Org Name:ESSENTIA HEALTH DETROIT LAKES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-364-7667
Mailing Address - Street 1:211 FRAZEE STREET EAST
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501
Mailing Address - Country:US
Mailing Address - Phone:218-847-3537
Mailing Address - Fax:218-847-4405
Practice Address - Street 1:211 FRAZEE STREET EAST
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501
Practice Address - Country:US
Practice Address - Phone:218-847-3537
Practice Address - Fax:218-847-4405
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN263266332B00000X, 3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN290678000Medicaid
MN2409995OtherNABP NUMBER
MN6347020001Medicare NSC