MEDICARE: ELK RIVER PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	261701	MN
4	3336C0003X	Community/Retail Pharmacy	265251	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2043890	OTHER		PK

General Provider Information

NPI Number	:	1013915040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELK RIVER PHARMACY

Provider Business Mailing Address
First Line	:	323 JACKSON AVE NW
Second Line	:
City	:	ELK RIVER
State	:	MN
Zip	:	55330
Country	:	US
Telephone Number	:	763-441-1353
Fax Number	:

Provider Business Practice Location Address
First Line	:	323 JACKSON AVE NW
Second Line	:
City	:	ELK RIVER
State	:	MN
Zip	:	55330
Country	:	US
Telephone Number	:	763-441-1353
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEBORAH LEEDAHL
Credential	:	PHARMD
Telephone Number	:	763-441-1353

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	12/20/2017

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Directions to “ELK RIVER PHARMACY ” Practice Location

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