Healthcare Provider Details

I. General information

NPI: 1902940604
Provider Name (Legal Business Name): MIDWEST MEDICAL HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 CORAL SEA ST NE STE 100
SAINT PAUL MN
55112-4395
US

IV. Provider business mailing address

PO BOX 18310
MINNEAPOLIS MN
55418-0310
US

V. Phone/Fax

Practice location:
  • Phone: 763-780-1500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number260897
License Number StateMN

VIII. Authorized Official

Name: LARRY LINDBERG
Title or Position: CEO
Credential: RPH
Phone: 763-780-1500