Healthcare Provider Details

I. General information

NPI: 1871755975
Provider Name (Legal Business Name): WEST SIDE COMMUNITY HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 7TH ST E
SAINT PAUL MN
55106-3871
US

IV. Provider business mailing address

PO BOX 9830
SALT LAKE CITY UT
84109-9830
US

V. Phone/Fax

Practice location:
  • Phone: 651-793-2250
  • Fax: 651-793-2240
Mailing address:
  • Phone: 651-793-2250
  • Fax: 651-793-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number263192
License Number StateMN

VIII. Authorized Official

Name: DEANNA GENGLER
Title or Position: PIC
Credential:
Phone: 651-793-2245