Provider Demographics
NPI:1891021390
Name:STATE OF MINNESOTA-MINNESOTA MANAGEMENT AND BUDGET
Entity Type:Organization
Organization Name:STATE OF MINNESOTA-MINNESOTA MANAGEMENT AND BUDGET
Other - Org Name:MINNESOTA VETERANS HOME - PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CENTRAL PHARMACY, PHARMACIST SENIOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-548-5962
Mailing Address - Street 1:5101 MINNEHAHA AVE BLDG 10
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1647
Mailing Address - Country:US
Mailing Address - Phone:612-548-5930
Mailing Address - Fax:612-548-5935
Practice Address - Street 1:5101 MINNEHAHA AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-1647
Practice Address - Country:US
Practice Address - Phone:612-548-5930
Practice Address - Fax:612-548-5935
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MINNESOTA-MINNESOTA MANAGEMENT AND BUDGET
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2012613336L0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2413499OtherNCPDP