Provider Demographics
NPI:1336174853
Name:ROLSETH DRUG CO
Entity Type:Organization
Organization Name:ROLSETH DRUG CO
Other - Org Name:LINDSTROM THRIFTY WHITE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:651-257-4074
Mailing Address - Street 1:30699 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045
Mailing Address - Country:US
Mailing Address - Phone:651-257-4074
Mailing Address - Fax:651-257-0919
Practice Address - Street 1:30699 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-8083
Practice Address - Country:US
Practice Address - Phone:651-257-4074
Practice Address - Fax:651-257-0919
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROLSETH DRUG CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-12
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2612852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN602514500Medicaid
MN602514500Medicaid