Organization
DEEPHAVEN PHCY INC
Active
Other names
DEEPHAVEN DRUG CO
Organization subpart
No
Provider details
NPI number
Authorized official
MARK LARSON (PRES)
(952) 473-4100
Entity
Organization
Contact information
Practice address
3428 COUNTY ROAD 101 S, WAYZATA, MN 55391-3421
(952) 473-4100
Mailing address
3428 COUNTY ROAD 101 S, WAYZATA, MN 55391-3421
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
2617598
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2401634
OTHER ID NUMBER
—
Enumeration date
04/25/2007
Last updated
09/12/2007
Update your record
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