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General NPI Number Information
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NPI Number | 1952431884
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Entity Type | Organization
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Legal Business Name | PRAIRIESTONE PHARMACY LLC
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 07/01/2011
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Provider Practice Location Address
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Address Line | 9995 W 69TH ST STE 102
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-3457
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Country | US
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Telephone | 952-656-5095
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Fax | 952-656-5096
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Provider Business Mailing Address
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Address Line | PO BOX 9830
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City | SALT LAKE CITY
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State | UT
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Zip | 84109-9830
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Country | US
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Telephone | 800-973-1955
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Fax | 317-575-6195
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Authorized Official
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Title or Position | CFO, SECRETARY, TREASURER
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Name | MATTHEW MIDDENDORF
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Credential |
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Telephone | 317-569-8234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 262983
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License Number State | MN
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