Provider Demographics
NPI:1053694885
Name:NORTHERN PINES MEDICAL CENTER
Entity type:Organization
Organization Name:NORTHERN PINES MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACUTE CARE PHARMAC
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMSCHE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-786-4346
Mailing Address - Street 1:5211 HIGHWAY 110
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705-1522
Mailing Address - Country:US
Mailing Address - Phone:218-229-4210
Mailing Address - Fax:218-229-4261
Practice Address - Street 1:5211 HIGHWAY 110
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MN
Practice Address - Zip Code:55705-1522
Practice Address - Country:US
Practice Address - Phone:218-229-4210
Practice Address - Fax:218-229-4261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336L0003X
MN2007493336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN173347800Medicaid
2045668OtherPK
2045668OtherPK
2411534OtherNCPDP PROVIDER IDENTIFICATION NUMBER