Provider Demographics
NPI:1942216361
Name:MAYO CLINIC HEALTH SYSTEM - PHARMACY & HOME MEDICAL, INC
Entity Type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM - PHARMACY & HOME MEDICAL, INC
Other - Org Name:MAYO CLINIC STORE WESTGATE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-838-5270
Mailing Address - Street 1:21 2ND ST SW STE 118
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-3197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1707 WESTGATE RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-4964
Practice Address - Country:US
Practice Address - Phone:715-838-5861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8530332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
51 21013OtherNCPDP
WI33184700Medicaid
BM9555357OtherDEA
51 21013OtherNCPDP