Provider Demographics
NPI:1811601123
Name:MINNESOTA ONCOLOGY HEMATOLOGY PA
Entity type:Organization
Organization Name:MINNESOTA ONCOLOGY HEMATOLOGY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:MEGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:651-255-8480
Mailing Address - Street 1:2250 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 110-N
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114
Mailing Address - Country:US
Mailing Address - Phone:651-602-5335
Mailing Address - Fax:651-602-5396
Practice Address - Street 1:10150 NIAGARA LN N
Practice Address - Street 2:STE 100
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7588
Practice Address - Country:US
Practice Address - Phone:763-712-2100
Practice Address - Fax:763-712-2190
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA ONCOLOGY HEMATOLOGY PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-11
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2157811-00Medicaid