Provider Demographics
NPI:1447326079
Name:STANLEY C. GALLAGHER D/B/A HERMAN CLINIC PHARMACY LLC
Entity type:Organization
Organization Name:STANLEY C. GALLAGHER D/B/A HERMAN CLINIC PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHCST
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:320-677-2220
Mailing Address - Street 1:204 5TH ST E
Mailing Address - Street 2:
Mailing Address - City:HERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:56248-0304
Mailing Address - Country:US
Mailing Address - Phone:320-677-2220
Mailing Address - Fax:320-677-2220
Practice Address - Street 1:204 5TH ST E
Practice Address - Street 2:
Practice Address - City:HERMAN
Practice Address - State:MN
Practice Address - Zip Code:56248-0304
Practice Address - Country:US
Practice Address - Phone:320-677-2220
Practice Address - Fax:320-677-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2621270333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2424795OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MN811760800Medicaid
MN811760800Medicaid