Provider Demographics
NPI:1871690974
Name:ST PETER PHARMACY LLC
Entity Type:Organization
Organization Name:ST PETER PHARMACY LLC
Other - Org Name:FALCON COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-788-7346
Mailing Address - Street 1:1801 OLD HIGHWAY 8 NW STE 121
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-2307
Mailing Address - Country:US
Mailing Address - Phone:651-788-7346
Mailing Address - Fax:651-340-1294
Practice Address - Street 1:1801 OLD HIGHWAY 8 NW STE 121
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-2307
Practice Address - Country:US
Practice Address - Phone:651-788-7346
Practice Address - Fax:651-340-1294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2639143336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121976OtherPK
MN035858400Medicaid
6343200001Medicare NSC