Healthcare Provider Details

I. General information

NPI: 1053471292
Provider Name (Legal Business Name): ERICKSON DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1583 HAMLINE AVE N
SAINT PAUL MN
55108-2139
US

IV. Provider business mailing address

1583 HAMLINE AVE N
SAINT PAUL MN
55108-2139
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-9645
  • Fax: 651-632-2164
Mailing address:
  • Phone: 651-646-9645
  • Fax: 651-632-2164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number262902
License Number StateMN

VIII. Authorized Official

Name: ROBERT KOZIOL
Title or Position: OWNER AND SEC TREAS
Credential: PHARM D
Phone: 952-469-2964