MEDICARE: OXYBORA DISTRIBUTING, 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	3336C0004X	Compounding Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy	263262	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2117770	OTHER		PK

General Provider Information

NPI Number	:	1609029297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OXYBORA DISTRIBUTING, LLC

Provider Business Mailing Address
First Line	:	4335 EXCELSIOR BLVD
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4811
Country	:	US
Telephone Number	:	952-922-4444
Fax Number	:	952-922-4455

Provider Business Practice Location Address
First Line	:	4335 EXCELSIOR BLVD
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4811
Country	:	US
Telephone Number	:	952-922-4444
Fax Number	:	952-922-4455

Authorized Official
Title or Position	:	CEO
Name	:	BORIS RABICHEV
Credential	:
Telephone Number	:	612-877-2842

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	08/26/2014

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