Healthcare Provider Details

I. General information

NPI: 1609925965
Provider Name (Legal Business Name): MIDWEST MEDICAL HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 CORAL SEA ST NE
SAINT PAUL MN
55112-4398
US

IV. Provider business mailing address

8400 CORAL SEA ST NE
SAINT PAUL MN
55112-4398
US

V. Phone/Fax

Practice location:
  • Phone: 763-780-0218
  • Fax: 763-780-2381
Mailing address:
  • Phone: 763-780-0218
  • Fax: 763-780-2381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number261420
License Number StateMN

VIII. Authorized Official

Name: LARRY LINDBERG
Title or Position: PIC/OWNER
Credential: RPH
Phone: 763-780-0218