MEDICARE: RX ANGELS LLC

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	3336C0003X	Community/Retail Pharmacy
2	333600000X	Pharmacy	265058	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2159961	OTHER		PK

General Provider Information

NPI Number	:	1154776748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RX ANGELS LLC

Provider Business Mailing Address
First Line	:	4445 W 77TH ST
Second Line	:	STE 122
City	:	EDINA
State	:	MN
Zip	:	55435-5133
Country	:	US
Telephone Number	:	651-214-1026
Fax Number	:	651-252-1263

Provider Business Practice Location Address
First Line	:	4445 W 77TH ST STE 122
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-5134
Country	:	US
Telephone Number	:	651-214-1026
Fax Number	:	651-252-1263

Authorized Official
Title or Position	:	CEO
Name	:	MARYPAT HABERMAS
Credential	:
Telephone Number	:	651-214-1026

Provider Enumeration Date	:	05/02/2016
Last Update Date	:	05/13/2016

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Directions to “RX ANGELS LLC ” Practice Location

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