Provider Demographics
NPI:1922112911
Name:MATHIESON ENTERPRISES INC
Entity Type:Organization
Organization Name:MATHIESON ENTERPRISES INC
Other - Org Name:BURCH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-871-1895
Mailing Address - Street 1:1942 HENNEPIN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3160
Mailing Address - Country:US
Mailing Address - Phone:612-871-1895
Mailing Address - Fax:612-871-1080
Practice Address - Street 1:1942 HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3160
Practice Address - Country:US
Practice Address - Phone:612-871-1895
Practice Address - Fax:612-871-1080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN26182703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN744418400Medicaid
2403195OtherNCPDP PROVIDER IDENTIFICATION NUMBER