Healthcare Provider Details

I. General information

NPI: 1407887599
Provider Name (Legal Business Name): FAMILY HEALTH SYSTEMS OF MOOSE LAKE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4570 COUNTY HWY 61
MOOSE LAKE MN
55767-9419
US

IV. Provider business mailing address

710 SOUTH KENWOOD AVE
MOOSE LAKE MN
55767
US

V. Phone/Fax

Practice location:
  • Phone: 218-485-2111
  • Fax: 218-485-8256
Mailing address:
  • Phone: 218-485-5671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number2608565
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2608565
License Number StateMN

VIII. Authorized Official

Name: MR. BILL STORCK
Title or Position: COO
Credential:
Phone: 217-485-5671