Healthcare Provider Details

I. General information

NPI: 1285621193
Provider Name (Legal Business Name): GERITOM MED INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 FLORIDA AVE S
BLOOMINGTON MN
55438-2553
US

IV. Provider business mailing address

10501 FLORIDA AVE S
BLOOMINGTON MN
55438-2553
US

V. Phone/Fax

Practice location:
  • Phone: 952-854-1190
  • Fax: 952-854-1082
Mailing address:
  • Phone: 952-854-1190
  • Fax: 952-854-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number261375
License Number StateMN

VIII. Authorized Official

Name: DR. JASON RYAN WACHTL
Title or Position: VICE PRESIDENT
Credential:
Phone: 952-854-1190