Provider Demographics
NPI:1740293489
Name:ESSENTIA HEALTH VIRGINIA LLC
Entity type:Organization
Organization Name:ESSENTIA HEALTH VIRGINIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:218-749-9414
Mailing Address - Street 1:901 9TH ST N
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2325
Mailing Address - Country:US
Mailing Address - Phone:218-749-9441
Mailing Address - Fax:218-749-9565
Practice Address - Street 1:901 9TH STREET NORTH
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792
Practice Address - Country:US
Practice Address - Phone:218-749-9414
Practice Address - Fax:218-749-9565
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S DULUTH CLINIC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-14
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336I0012X
MN26089213336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2412118OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN900019400Medicaid