Provider Demographics
NPI:1447341011
Name:SOUTHTOWN ECONODRUG
Entity type:Organization
Organization Name:SOUTHTOWN ECONODRUG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MYRON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-367-2196
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:OTTERTAIL
Mailing Address - State:MN
Mailing Address - Zip Code:56571-0154
Mailing Address - Country:US
Mailing Address - Phone:218-367-2196
Mailing Address - Fax:218-367-2197
Practice Address - Street 1:320 MN HWY 78 N.
Practice Address - Street 2:
Practice Address - City:OTTERTAIL
Practice Address - State:MN
Practice Address - Zip Code:56571
Practice Address - Country:US
Practice Address - Phone:218-367-2196
Practice Address - Fax:218-367-2197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262612-3333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0776850002Medicare ID - Type UnspecifiedMINNESOTA MEDICARE