=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376848333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVACEK HEALTHMART PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2011
-----------------------------------------------------
Last Update Date | 04/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 STATE HWY 11 E
-----------------------------------------------------
City | GREENBUSH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-782-3456
-----------------------------------------------------
Fax | 218-782-3458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 278
-----------------------------------------------------
City | GREENBUSH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56726-0278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-782-2221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIEF PHARMACIST
-----------------------------------------------------
Name | KAREN NOVACEK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 218-469-0631
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 263641
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------