Healthcare Provider Details

I. General information

NPI: 1033458922
Provider Name (Legal Business Name): MINNESOTA INDEPENDENT COOPERATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2013
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2980 COMMERS DR STE 200
EAGAN MN
55121-2370
US

IV. Provider business mailing address

2980 COMMERS DR STE 200
EAGAN MN
55121-2370
US

V. Phone/Fax

Practice location:
  • Phone: 800-940-1934
  • Fax:
Mailing address:
  • Phone: 800-940-1934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number361687
License Number StateMN

VIII. Authorized Official

Name: JAMES RUSSO
Title or Position: VP OF OPERATIONS
Credential:
Phone: 651-686-5011