Provider Demographics
NPI:1528121308
Name:NORTH SHORE PHARMACY LTD
Entity type:Organization
Organization Name:NORTH SHORE PHARMACY LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:MALSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:612-240-7571
Mailing Address - Street 1:133 SUMMIT ST STE 337
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803
Mailing Address - Country:US
Mailing Address - Phone:612-240-7571
Mailing Address - Fax:844-674-6737
Practice Address - Street 1:21 WEST HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604
Practice Address - Country:US
Practice Address - Phone:218-387-1133
Practice Address - Fax:218-387-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2602558333600000X
MN2630223336C0003X
3336C0003X, 3336L0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN460258700Medicaid
MN002432000Medicaid