Provider Demographics
NPI:1760792691
Name:GOODRICH PHARMACY FRIDLEY
Entity Type:Organization
Organization Name:GOODRICH PHARMACY FRIDLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:763-717-0222
Mailing Address - Street 1:480 OSBORNE RD SUITE 180
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432
Mailing Address - Country:US
Mailing Address - Phone:763-717-0222
Mailing Address - Fax:763-208-1545
Practice Address - Street 1:480 OSBORNE RD SUITE 180
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432
Practice Address - Country:US
Practice Address - Phone:763-780-0222
Practice Address - Fax:763-208-1545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2635983336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy