Provider Demographics
NPI:1790889756
Name:FAIRVIEW RANJIE REG HLTH SVS
Entity Type:Organization
Organization Name:FAIRVIEW RANJIE REG HLTH SVS
Other - Org Name:FAIRVIEW MESABA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-362-6657
Mailing Address - Street 1:750 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 E 34TH ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2341
Practice Address - Country:US
Practice Address - Phone:218-263-4922
Practice Address - Fax:218-362-6782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26132883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2405466OtherOTHER ID NUMBER
2405466OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MN411016100Medicaid