Provider Demographics
NPI:1043304447
Name:SNYDERS DRUG
Entity type:Organization
Organization Name:SNYDERS DRUG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:RISTAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-936-2404
Mailing Address - Street 1:14525 HIGHWAY 7
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-3734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7658 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3103
Practice Address - Country:US
Practice Address - Phone:763-561-3910
Practice Address - Fax:763-503-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2617954333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN025758300Medicaid
2417346OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MN0257583 00Medicaid
0340480028Medicare ID - Type Unspecified
MN0257583 00Medicaid