Provider Demographics
NPI:1952431884
Name:PRAIRIESTONE PHARMACY LLC
Entity type:Organization
Organization Name:PRAIRIESTONE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO, SECRETARY, TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-569-8234
Mailing Address - Street 1:PO BOX 9830
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9830
Mailing Address - Country:US
Mailing Address - Phone:800-973-1955
Mailing Address - Fax:317-575-6195
Practice Address - Street 1:9995 W 69TH ST
Practice Address - Street 2:STE 102
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3457
Practice Address - Country:US
Practice Address - Phone:952-656-5095
Practice Address - Fax:952-656-5096
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARCADIA RESOURCES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-07
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN778630000Medicaid