NPIMap

Organization Active NPI

St. Cloud Hospital

Doing business as CentraCare Pharmacy Health Plaza

  • Community/Retail Pharmacy
  • Saint Cloud, MN
National Provider Identifier
1013966175
Registry record updated Apr 20, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
2620682 Issued in MN
Legal business name
ST. CLOUD HOSPITAL
Doing business as
CentraCare Pharmacy Health Plaza
Practice address
1900 Centracare Circle
Suite 1350
St Cloud, MN 56303
Phone
(320) 229-4904
Fax
(320) 229-5168
NPI assigned
May 8, 2006
Last updated
Apr 20, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 20, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Matthew P. Kunkel
Title
Vice President
Phone
(320) 251-2700

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X 2620682 MN Primary

Addresses

Primary practice location

1900 Centracare Circle
Suite 1350
St Cloud, MN 56303

Mailing address

1900 Centracare Circle
Suite 1350
St Cloud, MN 56303
Phone (320) 229-4904

Other identifiers 2

IdentifierTypeStateIssuer
05092Y800MedicaidMN
2424543OtherNCPDP

Other names 1

  • CentraCare Pharmacy Health Plaza Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20220602000631 MN DME Supplier - Pharmacy 4880594779 Practice locations: Saint Cloud, MN
O20220623000730 MN Part B Supplier - Mass Immunization (Roster Biller Only) 4880594779 Practice locations: Saint Cloud, MN

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
St Cloud Hosp15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

Organizations that report the same tax identification number in the National Provider Directory.

View all 14

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

1900 Centracare Cir
Ste 1350
Saint Cloud, MN 56303
Phone (320) 229-4804

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Centracare - St Cloud Hospital Inpatient RehabilitationSaint Cloud, MN, CCN 24T036 Hospital Operational/Managerial Control Apr 20, 2015

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147046400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1650412800000",
    "number": "1013966175",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1900 CENTRACARE CIRCLE",
            "address_2": "SUITE 1350",
            "city": "ST CLOUD",
            "state": "MN",
            "postal_code": "56303",
            "telephone_number": "320-229-4904",
            "fax_number": "320-229-5168"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1900 CENTRACARE CIRCLE",
            "address_2": "SUITE 1350",
            "city": "ST CLOUD",
            "state": "MN",
            "postal_code": "56303",
            "telephone_number": "320-229-4904",
            "fax_number": "320-229-5168"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. CLOUD HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-08",
        "last_updated": "2022-04-20",
        "certification_date": "2022-04-20",
        "status": "A",
        "authorized_official_last_name": "KUNKEL",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_middle_name": "P.",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "320-251-2700"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MN",
            "license": "2620682",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "05092Y800",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "2424543",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CentraCare Pharmacy Health Plaza",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CentraCare Pharmacy Health Plaza",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Cloud, MN

Sources for this page

Verify at the official NPI Registry.