Provider Demographics
NPI:1386787729
Name:MATTSON PHARMACY, INC
Entity type:Organization
Organization Name:MATTSON PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESROSIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-463-2465
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:GREENBUSH
Mailing Address - State:MN
Mailing Address - Zip Code:56726-0039
Mailing Address - Country:US
Mailing Address - Phone:218-782-2366
Mailing Address - Fax:218-782-2365
Practice Address - Street 1:152 MAIN ST N
Practice Address - Street 2:
Practice Address - City:GREENBUSH
Practice Address - State:MN
Practice Address - Zip Code:56726-4015
Practice Address - Country:US
Practice Address - Phone:218-782-2366
Practice Address - Fax:218-782-2365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN260108332B00000X, 3336C0003X, 3336C0004X
2601083336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2409604OtherNCPDP NUMBER
MN2601083OtherPHARMACY LICENSE
MN338257500Medicaid
MN6319469OtherMN TAX ID NUMBER
MN6319469OtherMN TAX ID NUMBER
MN338257500Medicaid