Healthcare Provider Details

I. General information

NPI: 1528121308
Provider Name (Legal Business Name): NORTH SHORE PHARMACY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 WEST HIGHWAY 61
GRAND MARAIS MN
55604
US

IV. Provider business mailing address

133 SUMMIT ST STE 337
DULUTH MN
55803
US

V. Phone/Fax

Practice location:
  • Phone: 218-387-1133
  • Fax: 218-387-2169
Mailing address:
  • Phone: 612-240-7571
  • Fax: 844-674-6737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2602558
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number263022
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. COREY TODD MALSTROM
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 612-240-7571