=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568785640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WACONIA PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2010
-----------------------------------------------------
Last Update Date | 03/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 FAXON RD N
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55368-9507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-467-2100
-----------------------------------------------------
Fax | 952-467-2489
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 FAXON RD N P.O. BOX 600
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55368-9507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-467-2100
-----------------------------------------------------
Fax | 952-467-2489
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JOHN CHARLES MARSDEN
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 952-467-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------