Provider Demographics
NPI:1487636213
Name:MINNESOTA STATE COLLEGES AND UNIVERSITIES
Entity type:Organization
Organization Name:MINNESOTA STATE COLLEGES AND UNIVERSITIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:507-389-2483
Mailing Address - Street 1:21 CARKOSKI CMNS
Mailing Address - Street 2:600 MAYWOOD AVE
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6030
Mailing Address - Country:US
Mailing Address - Phone:507-389-2483
Mailing Address - Fax:507-389-2206
Practice Address - Street 1:21 CARKOSKI CMNS
Practice Address - Street 2:MINNESOTA STATE UNIVERSITY, MANKATO
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6030
Practice Address - Country:US
Practice Address - Phone:507-389-2483
Practice Address - Fax:507-389-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
MN200808333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2044574OtherPK
MN7773137Medicaid