Provider Demographics
NPI:1134231590
Name:AITKIN PHARMACY SERVICES, LLC
Entity type:Organization
Organization Name:AITKIN PHARMACY SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:HUTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-808-0873
Mailing Address - Street 1:901 4TH STREET
Mailing Address - Street 2:SUITE 170
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016
Mailing Address - Country:US
Mailing Address - Phone:715-808-0873
Mailing Address - Fax:715-953-4201
Practice Address - Street 1:25 2ND STREET, NE
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431
Practice Address - Country:US
Practice Address - Phone:218-927-3754
Practice Address - Fax:218-927-6349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2636473336C0003X, 333600000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2415443OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN551060100Medicaid
2415443OtherNCPDP PROVIDER IDENTIFICATION NUMBER