Provider Demographics
NPI:1669601878
Name:PRIME THERAPEUTICS LLC
Entity type:Organization
Organization Name:PRIME THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-777-4592
Mailing Address - Street 1:1305 CORPORATE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1204
Mailing Address - Country:US
Mailing Address - Phone:612-444-4789
Mailing Address - Fax:
Practice Address - Street 1:1305 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1204
Practice Address - Country:US
Practice Address - Phone:612-444-4789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262623-33336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy