Provider Demographics
NPI:1609925965
Name:MIDWEST MEDICAL HOLDINGS LLC
Entity type:Organization
Organization Name:MIDWEST MEDICAL HOLDINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:763-780-0218
Mailing Address - Street 1:8400 CORAL SEA ST NE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55112-4398
Mailing Address - Country:US
Mailing Address - Phone:763-780-0218
Mailing Address - Fax:763-780-2381
Practice Address - Street 1:8400 CORAL SEA ST NE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55112-4398
Practice Address - Country:US
Practice Address - Phone:763-780-0218
Practice Address - Fax:763-780-2381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MN2614203336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN950816300Medicaid
2047435OtherPK