=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639474612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE BEAR HEALTH MART PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2011
-----------------------------------------------------
Last Update Date | 05/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2008 COUNTY ROAD E E
-----------------------------------------------------
City | WHITE BEAR LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55110-7333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-289-4300
-----------------------------------------------------
Fax | 651-289-4301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2008 COUNTY ROAD E E
-----------------------------------------------------
City | WHITE BEAR LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55110-7333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-289-4300
-----------------------------------------------------
Fax | 651-289-4301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | DR. JOSEPH NORMAN JORGENSON
-----------------------------------------------------
Credential | PHARM.D.
-----------------------------------------------------
Telephone | 651-289-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------