Provider Demographics
NPI:1154415552
Name:SNYDERS DRUG
Entity type:Organization
Organization Name:SNYDERS DRUG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:RISTAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-936-2404
Mailing Address - Street 1:14525 HIGHWAY 7
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-3734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 W 3RD ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8791
Practice Address - Country:US
Practice Address - Phone:763-295-5890
Practice Address - Fax:763-271-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2619897333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1034081 00Medicaid
MN103408100Medicaid
2403157OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MN1034081 00Medicaid
2403157OtherOTHER ID NUMBER-COMMERCIAL NUMBER