Healthcare Provider Details

I. General information

NPI: 1073581302
Provider Name (Legal Business Name): MINNESOTA STATE COLLEGES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 6TH ST S
SAINT CLOUD MN
56301-4491
US

IV. Provider business mailing address

720 4TH AVE S
SAINT CLOUD MN
56301-4442
US

V. Phone/Fax

Practice location:
  • Phone: 320-308-4852
  • Fax: 320-308-4878
Mailing address:
  • Phone: 320-308-4852
  • Fax: 320-308-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number200814
License Number StateMN

VIII. Authorized Official

Name: LYNN LEAF
Title or Position: PHARMACIST IN CHARGE
Credential: BS
Phone: 320-308-4852