Healthcare Provider Details

I. General information

NPI: 1104260868
Provider Name (Legal Business Name): NIS PHARMACY SERVICES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1472 COUNTY ROAD 5
LONGVILLE MN
56655-3002
US

IV. Provider business mailing address

108 S 6TH ST
BRAINERD MN
56401-3575
US

V. Phone/Fax

Practice location:
  • Phone: 218-363-2640
  • Fax: 218-363-2641
Mailing address:
  • Phone: 218-829-0347
  • Fax: 218-829-4701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number264101
License Number StateMN

VIII. Authorized Official

Name: MICHAEL SCHWARTZWALD
Title or Position: PRESIDENT
Credential:
Phone: 218-829-0347