Healthcare Provider Details

I. General information

NPI: 1508378167
Provider Name (Legal Business Name): PRAIRIECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 ZANE AVE N
BROOKLYN PARK MN
55443-1814
US

IV. Provider business mailing address

9400 ZANE AVE N
BROOKLYN PARK MN
55443-1814
US

V. Phone/Fax

Practice location:
  • Phone: 763-762-8800
  • Fax: 763-315-4469
Mailing address:
  • Phone: 763-762-8800
  • Fax: 763-315-4469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number264804
License Number StateMN

VIII. Authorized Official

Name: JOHN EGAN RYAN
Title or Position: GENERAL COUNSEL
Credential: JD
Phone: 763-762-6802