Provider Demographics
NPI:1013966175
Name:ST. CLOUD HOSPITAL
Entity Type:Organization
Organization Name:ST. CLOUD HOSPITAL
Other - Org Name:CENTRACARE PHARMACY HEALTH PLAZA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:P
Authorized Official - Last Name:KUNKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-251-2700
Mailing Address - Street 1:1900 CENTRACARE CIRCLE
Mailing Address - Street 2:SUITE 1350
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-229-4904
Mailing Address - Fax:320-229-5168
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:SUITE 1350
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-229-4904
Practice Address - Fax:320-229-5168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26206823336C0003X, 3336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2424543OtherNCPDP
MN05092Y800Medicaid
0968910004Medicare NSC