Provider Demographics
NPI:1336255744
Name:THE DULUTH CLINIC, LTD
Entity Type:Organization
Organization Name:THE DULUTH CLINIC, LTD
Other - Org Name:ESSENTIA HEALTH HERMANTOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:4855 W ARROWHEAD RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3936
Mailing Address - Country:US
Mailing Address - Phone:218-786-3549
Mailing Address - Fax:218-786-3691
Practice Address - Street 1:4855 W ARROWHEAD RD
Practice Address - Street 2:SUITE A
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-3936
Practice Address - Country:US
Practice Address - Phone:218-786-3549
Practice Address - Fax:218-786-3691
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-21
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26127553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24-21701OtherNCPDP
MN359723700Medicaid
WI33207700Medicaid
MN573OtherTHE DULUTH CLINIC, LTD CHAIN CODE
MN359723700Medicaid