Provider Demographics
NPI:1184723611
Name:IVERSON CORNER DRUG INC
Entity type:Organization
Organization Name:IVERSON CORNER DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OKERLUND
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:218-444-3000
Mailing Address - Street 1:408 MINNESOTA AVE NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3127
Mailing Address - Country:US
Mailing Address - Phone:218-444-3000
Mailing Address - Fax:218-444-6640
Practice Address - Street 1:408 MINNESOTA AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3127
Practice Address - Country:US
Practice Address - Phone:218-444-3000
Practice Address - Fax:218-444-6640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MN2606933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN506060500Medicaid
2046698OtherPK
MN506060500Medicaid