Healthcare Provider Details

I. General information

NPI: 1528112976
Provider Name (Legal Business Name): COMMUNITY CARE PHARMACY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 2ND AVE NW
SAINT JOSEPH MN
56374-4106
US

IV. Provider business mailing address

PO BOX 100
SAINT JOSEPH MN
56374-0100
US

V. Phone/Fax

Practice location:
  • Phone: 320-271-1135
  • Fax: 320-271-1137
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2626385
License Number StateMN

VIII. Authorized Official

Name: GERALD WENSMENN
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 320-271-1135