=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104360973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROUP HEALTH PLAN, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2016
-----------------------------------------------------
Last Update Date | 06/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 PARK NICOLLET BLVD STE 1170
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-977-3050
-----------------------------------------------------
Fax | 952-883-9747
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | MSC 21111B PO BOX 1309
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-967-6876
-----------------------------------------------------
Fax | 952-967-6667
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP PHARMACY OPERATIONS
-----------------------------------------------------
Name | DAVID BUSCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-967-6876
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------