Healthcare Provider Details

I. General information

NPI: 1528148525
Provider Name (Legal Business Name): CROSSTOWN DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 CORAL SEA ST, SUITE 525
MOUNDS VIEW MN
55112-4398
US

IV. Provider business mailing address

8400 CORAL SEA ST, SUITE 525
MOUNDS VIEW MN
55112-4398
US

V. Phone/Fax

Practice location:
  • Phone: 763-780-1500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number259796-4
License Number StateMN

VIII. Authorized Official

Name: MR. LARRY LINDBERG
Title or Position: CEO
Credential:
Phone: 763-780-1500