Provider Demographics
NPI:1154356657
Name:E L ANDERSON CITY DRUG STORE
Entity type:Organization
Organization Name:E L ANDERSON CITY DRUG STORE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HOOPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-283-3061
Mailing Address - Street 1:314 3RD ST
Mailing Address - Street 2:PO BOX 111
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649
Mailing Address - Country:US
Mailing Address - Phone:218-283-3061
Mailing Address - Fax:218-283-3423
Practice Address - Street 1:314 3RD ST
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649
Practice Address - Country:US
Practice Address - Phone:218-283-3061
Practice Address - Fax:218-283-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200638-7333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN331260700Medicaid
70362OtherBLUE CROSS
2405579OtherNABP
MN331260700Medicaid