Provider Demographics
NPI:1194101766
Name:COBORNS INC
Entity type:Organization
Organization Name:COBORNS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:R
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:320-534-2743
Mailing Address - Street 1:PO BOX 6146
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-6146
Mailing Address - Country:US
Mailing Address - Phone:320-534-2745
Mailing Address - Fax:320-203-1095
Practice Address - Street 1:710 FRANKIE LN
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1914
Practice Address - Country:US
Practice Address - Phone:320-679-2363
Practice Address - Fax:320-679-1620
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COBORNS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-06
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119447302R00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1831261502Medicaid
2406987OtherNCPDP