Healthcare Provider Details

I. General information

NPI: 1871733501
Provider Name (Legal Business Name): STORCHAK PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2009
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NICOLLET MALL
MPLS MN
55403
US

IV. Provider business mailing address

1200 NICOLLET MALL
MPLS. MN
55403
US

V. Phone/Fax

Practice location:
  • Phone: 612-354-3400
  • Fax: 612-677-3330
Mailing address:
  • Phone: 612-354-3400
  • Fax: 612-677-3330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number263333
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number263333
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number263333
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier263333
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMINNESOTTA PHARMACY LICENSE

VIII. Authorized Official

Name: MR. BARRY DAVID ZOSS
Title or Position: PHARMACIST IN CHARGE
Credential: RPH.
Phone: 612-354-3400