Healthcare Provider Details

I. General information

NPI: 1528485877
Provider Name (Legal Business Name): PERHAM HOSPITAL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CONEY ST W
PERHAM MN
56573-2102
US

IV. Provider business mailing address

6501 CITY WEST PKWY
EDEN PRAIRIE MN
55344-3248
US

V. Phone/Fax

Practice location:
  • Phone: 218-347-1571
  • Fax:
Mailing address:
  • Phone: 952-653-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DUANE WALLACE
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 218-347-1571