Healthcare Provider Details

I. General information

NPI: 1033254669
Provider Name (Legal Business Name): BLAIR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 BELGRADE AVE
NORTH MANKATO MN
56003-3809
US

IV. Provider business mailing address

406 BELGRADE AVE
NORTH MANKATO MN
56003-3809
US

V. Phone/Fax

Practice location:
  • Phone: 507-387-6521
  • Fax: 507-387-7982
Mailing address:
  • Phone:
  • Fax:

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 Number2609386
License Number StateMN

VIII. Authorized Official

Name: DENA FERMAN
Title or Position: THIRD PARTY PLAN COORDINATOR
Credential:
Phone: 314-993-6000