Provider Demographics
NPI:1700895760
Name:MINNESOTA DRUG ACQUISITION CO LLC
Entity Type:Organization
Organization Name:MINNESOTA DRUG ACQUISITION CO LLC
Other - Org Name:HANSON DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:KEAVENY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:612-227-7811
Mailing Address - Street 1:102 EAST 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MN
Mailing Address - Zip Code:55396-0000
Mailing Address - Country:US
Mailing Address - Phone:507-647-5351
Mailing Address - Fax:507-647-6445
Practice Address - Street 1:103 E 2ND ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MN
Practice Address - Zip Code:55396
Practice Address - Country:US
Practice Address - Phone:507-647-5351
Practice Address - Fax:507-647-6445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2631943336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN631560700Medicaid
2409387OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6255420008Medicare NSC