MEDICARE: MIDWEST MEDICAL HOLDINGS 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	333600000X	Pharmacy
3	3336L0003X	Long Term Care Pharmacy	261420	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2047435	OTHER		PK

General Provider Information

NPI Number	:	1609925965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST MEDICAL HOLDINGS LLC

Provider Business Mailing Address
First Line	:	8400 CORAL SEA ST NE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55112-4398
Country	:	US
Telephone Number	:	763-780-0218
Fax Number	:	763-780-2381

Provider Business Practice Location Address
First Line	:	8400 CORAL SEA ST NE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55112-4398
Country	:	US
Telephone Number	:	763-780-0218
Fax Number	:	763-780-2381

Authorized Official
Title or Position	:	PIC/OWNER
Name	:	LARRY LINDBERG
Credential	:	RPH
Telephone Number	:	763-780-0218

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	04/13/2015

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