MEDICARE: COBORNS INC

Medicare Provider Information

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	3336C0002X	Clinic Pharmacy
4	3336L0003X	Long Term Care Pharmacy
5	3336C0003X	Community/Retail Pharmacy	263191	MN

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2049512	OTHER		PK

NPI Number	:	1609037134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COBORNS INC

Provider Business Mailing Address
First Line	:	PO BOX 6146
Second Line	:	PO BOX 6146
City	:	SAINT CLOUD
State	:	MN
Zip	:	56302-6146
Country	:	US
Telephone Number	:	320-534-2745
Fax Number	:	320-203-1095

Provider Business Practice Location Address
First Line	:	600 PETERSON PKWY
Second Line	:
City	:	NEW LONDON
State	:	MN
Zip	:	56273-7823
Country	:	US
Telephone Number	:	320-354-3998
Fax Number	:	320-354-3997

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	LYNN R YOUNG
Credential	:	RPH
Telephone Number	:	320-354-2743

Provider Enumeration Date	:	06/18/2008
Last Update Date	:	08/21/2020

10 UNION SQ E , BETH ISRAEL MED CTR- DEPT OF REHAB MEDICARE
NEW YORK, NY
10003-3314

Practice Phone: 212-420-2757
Practice Fax: