MEDICARE: CENTRACARE PHARMACY SERVICES LLC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	261081	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2047034	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386600641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRACARE PHARMACY SERVICES LLC

Provider Business Mailing Address
First Line	:	1555 NORTHWAY DR
Second Line	:	SUITE 150
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-4555
Country	:	US
Telephone Number	:	320-240-3160
Fax Number	:	320-255-5876

Provider Business Practice Location Address
First Line	:	1555 NORTHWAY DR STE 150
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-4912
Country	:	US
Telephone Number	:	320-240-3160
Fax Number	:	320-255-5876

Authorized Official
Title or Position	:	COORDINATOR RETAIL PHARM. SE
Name	:	KEITH KARSKY
Credential	:	RPH
Telephone Number	:	320-251-2700

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	07/05/2016

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