MEDICARE: ERICKSON DRUG INC

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	2004130	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	2044557	OTHER	PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629159736
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERICKSON DRUG INC

Provider Business Mailing Address
First Line	:	PO BOX 808
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-0808
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20751 HOLYOKE AVE
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-9825
Country	:	US
Telephone Number	:	952-469-2964
Fax Number	:	952-469-6753

Authorized Official
Title or Position	:	OWNER AND SECRETARY TREASURER
Name	:	ROBERT KOZIOL
Credential	:	PHARMD
Telephone Number	:	952-469-2964

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	06/27/2015

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