Healthcare Provider Details

I. General information

NPI: 1568785640
Provider Name (Legal Business Name): WACONIA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 FAXON RD N
NORWOOD MN
55368-9507
US

IV. Provider business mailing address

402 FAXON RD N P.O. BOX 600
NORWOOD MN
55368-9507
US

V. Phone/Fax

Practice location:
  • Phone: 952-467-2100
  • Fax: 952-467-2489
Mailing address:
  • Phone: 952-467-2100
  • Fax: 952-467-2489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN CHARLES MARSDEN
Title or Position: OWNER
Credential: RPH
Phone: 952-467-2100