Healthcare Provider Details

I. General information

NPI: 1609029297
Provider Name (Legal Business Name): OXYBORA DISTRIBUTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4335 EXCELSIOR BLVD
ST LOUIS PARK MN
55416-4811
US

IV. Provider business mailing address

4335 EXCELSIOR BLVD
ST LOUIS PARK MN
55416-4811
US

V. Phone/Fax

Practice location:
  • Phone: 952-922-4444
  • Fax: 952-922-4455
Mailing address:
  • Phone: 952-922-4444
  • Fax: 952-922-4455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number263262
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BORIS RABICHEV
Title or Position: CEO
Credential:
Phone: 612-877-2842