Provider Demographics
NPI:1538792353
Name:CHILDREN'S HEALTH CARE
Entity type:Organization
Organization Name:CHILDREN'S HEALTH CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OUTPATIENT PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHESTEVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:612-813-5922
Mailing Address - Street 1:PO BOX 860123
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0123
Mailing Address - Country:US
Mailing Address - Phone:612-813-7290
Mailing Address - Fax:612-813-7296
Practice Address - Street 1:2530 CHICAGO AVE S
Practice Address - Street 2:CSC 225
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4289
Practice Address - Country:US
Practice Address - Phone:612-813-7290
Practice Address - Fax:612-813-7296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-20
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy