Provider Demographics
NPI:1760440846
Name:CENTRACARE HEALTH - PAYNESVILLE LLC
Entity Type:Organization
Organization Name:CENTRACARE HEALTH - PAYNESVILLE LLC
Other - Org Name:CENTRACARE HEALTH - PAYNESVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-255-5665
Mailing Address - Street 1:200 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PAYNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56362-1445
Mailing Address - Country:US
Mailing Address - Phone:320-243-3767
Mailing Address - Fax:320-243-7519
Practice Address - Street 1:200 W 1ST ST
Practice Address - Street 2:
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362
Practice Address - Country:US
Practice Address - Phone:320-243-3767
Practice Address - Fax:320-243-7519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
300173OtherHOSP. UCARE
MN333747200Medicaid
5003780OtherHOSP. MEDICA
10141401OtherHOSP. HEALTH PARTNERS
03072202705OtherHOSP. PRIMEWEST
1006079OtherHOSP. PREF. ONE
1802HPAOtherHOSP & SWING BED BCBS
MN333747200Medicaid
10141401OtherHOSP. HEALTH PARTNERS
MN241349Medicare Oscar/Certification