MEDICARE: MEDSTAT 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	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1669862405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDSTAT LLC

Provider Business Mailing Address
First Line	:	6501 CITY WEST PKWY
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-3248
Country	:	US
Telephone Number	:	952-653-2525
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 N MAIN ST
Second Line	:
City	:	NAPPANEE
State	:	IN
Zip	:	46550-1038
Country	:	US
Telephone Number	:	574-773-2509
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MEGAN MARTIN
Credential	:
Telephone Number	:	574-372-7638

Provider Enumeration Date	:	02/02/2015
Last Update Date	:	12/30/2015

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