Healthcare Provider Details

I. General information

NPI: 1952742256
Provider Name (Legal Business Name): STATE OF MINNESOTA-MINNESOTA MANAGEMENT AND BUDGET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 OUTER DR
SILVER BAY MN
55614-1133
US

IV. Provider business mailing address

5101 MINNEHAHA AVE BLDG 10
MINNEAPOLIS MN
55417-1647
US

V. Phone/Fax

Practice location:
  • Phone: 218-226-6300
  • Fax:
Mailing address:
  • Phone: 612-548-5962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number00381
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MARY ELIZABETH JOHNSON
Title or Position: CENTRAL PHARMACY, PHARMACIST SENIOR
Credential:
Phone: 612-548-5962