Healthcare Provider Details

I. General information

NPI: 1447341011
Provider Name (Legal Business Name): SOUTHTOWN ECONODRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 MN HWY 78 N.
OTTERTAIL MN
56571
US

IV. Provider business mailing address

PO BOX 154
OTTERTAIL MN
56571-0154
US

V. Phone/Fax

Practice location:
  • Phone: 218-367-2196
  • Fax: 218-367-2197
Mailing address:
  • Phone: 218-367-2196
  • Fax: 218-367-2197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number262612-3
License Number StateMN

VIII. Authorized Official

Name: PAULA L MYRON
Title or Position: PHARMACIST/OWNER
Credential: R.P.H
Phone: 218-367-2196