Provider Demographics
NPI:1871508481
Name:WARREN PHARMACY INC
Entity Type:Organization
Organization Name:WARREN PHARMACY INC
Other - Org Name:WARREN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, SHAREHOLDER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:218-289-5859
Mailing Address - Street 1:103 W JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MN
Mailing Address - Zip Code:56762-1102
Mailing Address - Country:US
Mailing Address - Phone:218-745-5481
Mailing Address - Fax:218-745-5482
Practice Address - Street 1:103 W JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762-1102
Practice Address - Country:US
Practice Address - Phone:218-745-5481
Practice Address - Fax:218-745-5482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045164OtherPK
MN418258800Medicaid