Provider Demographics
NPI:1700979861
Name:CHILDRENS HEALTH CARE
Entity Type:Organization
Organization Name:CHILDRENS HEALTH CARE
Other - Org Name:CHILDREN'S HOSPITAL AND CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR ST.PAUL PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNZLI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:651-220-6806
Mailing Address - Street 1:PO BOX 860123
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0112
Mailing Address - Country:US
Mailing Address - Phone:651-220-6806
Mailing Address - Fax:651-220-6964
Practice Address - Street 1:345 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2346
Practice Address - Country:US
Practice Address - Phone:651-220-6963
Practice Address - Fax:651-220-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MN26199493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN090953000Medicaid
2048204OtherPK