Provider Demographics
NPI:1881750859
Name:IVANHOE FAMILY PHARMACY, INC
Entity type:Organization
Organization Name:IVANHOE FAMILY PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:ROST
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:507-694-1166
Mailing Address - Street 1:366 E GEORGE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:IVANHOE
Mailing Address - State:MN
Mailing Address - Zip Code:56142-9707
Mailing Address - Country:US
Mailing Address - Phone:507-694-1166
Mailing Address - Fax:507-694-1167
Practice Address - Street 1:366 E GEORGE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:IVANHOE
Practice Address - State:MN
Practice Address - Zip Code:56142-9707
Practice Address - Country:US
Practice Address - Phone:507-694-1166
Practice Address - Fax:507-694-1167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
MN2629253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN716150000Medicaid
MN5834970001Medicare NSC