Provider Demographics
NPI:1902940604
Name:MIDWEST MEDICAL HOLDINGS LLC
Entity Type:Organization
Organization Name:MIDWEST MEDICAL HOLDINGS LLC
Other - Org Name:MIDWEST IV AND HOMECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:763-780-1500
Mailing Address - Street 1:PO BOX 18310
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-0310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8400 CORAL SEA ST NE STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55112-4395
Practice Address - Country:US
Practice Address - Phone:763-780-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336S0011X
MN2608973336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN569860000Medicaid
2047033OtherPK
0621340001Medicare NSC