Provider Demographics
NPI:1992202048
Name:TWIN CITIES PHARMARCY LLC
Entity type:Organization
Organization Name:TWIN CITIES PHARMARCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEWODROS
Authorized Official - Middle Name:
Authorized Official - Last Name:GEMEDA
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED PHARMACY
Authorized Official - Phone:612-315-5687
Mailing Address - Street 1:3945 W 141ST ST
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2690
Mailing Address - Country:US
Mailing Address - Phone:612-250-3407
Mailing Address - Fax:
Practice Address - Street 1:133 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3119
Practice Address - Country:US
Practice Address - Phone:613-315-5687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========Medicaid