Healthcare Provider Details

I. General information

NPI: 1639566649
Provider Name (Legal Business Name): ST PAUL PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY AVE W
SAINT PAUL MN
55103-2048
US

IV. Provider business mailing address

301 UNIVERSITY AVE W
SAINT PAUL MN
55103-2048
US

V. Phone/Fax

Practice location:
  • Phone: 651-447-7113
  • Fax: 651-447-7112
Mailing address:
  • Phone: 651-447-7113
  • Fax: 651-447-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number118487
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number118487
License Number StateMN

VIII. Authorized Official

Name: DR. KY NOUKY FANG
Title or Position: PHARMACIST
Credential: PHARM D
Phone: 651-447-7113