Healthcare Provider Details

I. General information

NPI: 1194101766
Provider Name (Legal Business Name): COBORNS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 FRANKIE LN
MORA MN
55051-1914
US

IV. Provider business mailing address

PO BOX 6146
SAINT CLOUD MN
56302-6146
US

V. Phone/Fax

Practice location:
  • Phone: 320-679-2363
  • Fax: 320-679-1620
Mailing address:
  • Phone: 320-534-2745
  • Fax: 320-203-1095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number119447
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MS. LYNN R YOUNG
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 320-534-2743