Healthcare Provider Details

I. General information

NPI: 1154467678
Provider Name (Legal Business Name): PERHAM HOSPITAL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 06/30/2014
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

1000 CONEY ST W
PERHAM MN
56573-2102
US

V. Phone/Fax

Practice location:
  • Phone: 218-347-1580
  • Fax: 218-347-1652
Mailing address:
  • Phone: 218-347-1580
  • Fax: 218-347-1652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number200303
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

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