Provider Demographics
NPI:1144281304
Name:MINNESOTA ONCOLOGY HEMATOLOGY PA
Entity type:Organization
Organization Name:MINNESOTA ONCOLOGY HEMATOLOGY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:651-255-8480
Mailing Address - Street 1:1580 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1127
Mailing Address - Country:US
Mailing Address - Phone:651-255-8480
Mailing Address - Fax:651-779-8989
Practice Address - Street 1:1580 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1127
Practice Address - Country:US
Practice Address - Phone:651-255-8480
Practice Address - Fax:651-779-8989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MN2619213336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33234600Medicaid
2047904OtherPK
MN215781100Medicaid
1145020009Medicare NSC