MEDICARE: ROLSETH DRUG CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	2612852	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336174853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROLSETH DRUG CO

Provider Business Mailing Address
First Line	:	30699 LINCOLN RD
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045
Country	:	US
Telephone Number	:	651-257-4074
Fax Number	:	651-257-0919

Provider Business Practice Location Address
First Line	:	30699 LINCOLN RD
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045-8083
Country	:	US
Telephone Number	:	651-257-4074
Fax Number	:	651-257-0919

Authorized Official
Title or Position	:	PIC
Name	:	MR. MATTHEW GARRISON
Credential	:	PHARMD
Telephone Number	:	651-257-4074

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/01/2008

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1134083744 — ROLSETH DRUG CO
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Directions to “ROLSETH DRUG CO ” Practice Location

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