MEDICARE: MIDWEST MEDICAL HOLDINGS 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	3336C0004X	Compounding Pharmacy
2	3336S0011X	Specialty Pharmacy
3	3336H0001X	Home Infusion Therapy Pharmacy	260897	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
2	2047033	OTHER		PK

General Provider Information

NPI Number	:	1902940604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST MEDICAL HOLDINGS LLC

Provider Business Mailing Address
First Line	:	PO BOX 18310
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-0310
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8400 CORAL SEA ST NE STE 100
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55112-4395
Country	:	US
Telephone Number	:	763-780-1500
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LARRY LINDBERG
Credential	:	RPH
Telephone Number	:	763-780-1500

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	10/17/2016

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