Healthcare Provider Details

I. General information

NPI: 1386787729
Provider Name (Legal Business Name): MATTSON PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 03/07/2023
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 MAIN ST N
GREENBUSH MN
56726-4015
US

IV. Provider business mailing address

PO BOX 39
GREENBUSH MN
56726-0039
US

V. Phone/Fax

Practice location:
  • Phone: 218-782-2366
  • Fax: 218-782-2365
Mailing address:
  • Phone: 218-782-2366
  • Fax: 218-782-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number260108
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number260108
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number260108
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number260108
License Number State

VIII. Authorized Official

Name: MRS. LINDA DESROSIER
Title or Position: MANAGER
Credential:
Phone: 218-463-2465