MEDICARE: SNYDERS DRUG

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	333600000X	Pharmacy	2617695	MN
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2400480	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1255425658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SNYDERS DRUG

Provider Business Mailing Address
First Line	:	14525 HIGHWAY 7
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-3734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 S BROADWAY
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55904-3862
Country	:	US
Telephone Number	:	507-288-1911
Fax Number	:	507-288-2615

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JODI RISTAU
Credential	:
Telephone Number	:	952-936-2404

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	08/06/2008

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