Provider Demographics
NPI:1023326980
Name:GRAND ITASCA CLINIC AND HOSPITAL
Entity type:Organization
Organization Name:GRAND ITASCA CLINIC AND HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-653-2565
Mailing Address - Street 1:6501 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3248
Mailing Address - Country:US
Mailing Address - Phone:952-653-2565
Mailing Address - Fax:
Practice Address - Street 1:1601 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-8648
Practice Address - Country:US
Practice Address - Phone:218-326-7503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND ITASCA CLINIC AND HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site