Healthcare Provider Details

I. General information

NPI: 1154776748
Provider Name (Legal Business Name): RX ANGELS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 W 77TH ST STE 122
EDINA MN
55435-5134
US

IV. Provider business mailing address

4445 W 77TH ST STE 122
EDINA MN
55435-5133
US

V. Phone/Fax

Practice location:
  • Phone: 651-214-1026
  • Fax: 651-252-1263
Mailing address:
  • Phone: 651-214-1026
  • Fax: 651-252-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number265058
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARYPAT HABERMAS
Title or Position: CEO
Credential:
Phone: 651-214-1026