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NPI Code Detail

MEDICARE: PRESCRIPTION SHOPPE IIOF DETROIT LAKES MN

MEDICARE: PRESCRIPTION SHOPPE IIOF DETROIT LAKES MN
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
1333600000XPharmacy
23336C0003XCommunity/Retail Pharmacy261074MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
22417966OTHERNCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number : 1669413092
Entity Type Code : Organization
Provider Name (Legal Business Name) : PRESCRIPTION SHOPPE IIOF DETROIT LAKES MN
Provider Business Mailing Address
First Line : 1245 WASHINGTON AVE
Second Line :
City : DETROIT LAKES
State : MN
Zip : 56501-3905
Country : US
Telephone Number : 218-846-2275
Fax Number : 218-846-2114
Provider Business Practice Location Address
First Line : 1245 WASHINGTON AVE
Second Line :
City : DETROIT LAKES
State : MN
Zip : 56501-3905
Country : US
Telephone Number : 218-846-2275
Fax Number : 218-846-2114
Authorized Official
Title or Position : OWNER
Name : DAVID BRENK
Credential : RPH
Telephone Number : 218-846-2275
Provider Enumeration Date : 06/09/2006
Last Update Date : 12/19/2009

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Directions to “PRESCRIPTION SHOPPE IIOF DETROIT LAKES MN ” Practice Location

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