Active NPI
Goodrich Pharmacy, Inc.
- Clinic Pharmacy
- Elk River, MN
National Provider Identifier
1174635171
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinic Pharmacy
- License
- 265080
- Legal business name
- GOODRICH PHARMACY, INC.
- Practice address
- 530 3Rd St NW
Elk River, MN 55330-1445 - Phone
- (763) 441-0764
- Fax
- (763) 587-4897
- NPI assigned
- Aug 31, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Stephanie Marie Davis
- Title
- Owner
- Phone
- (763) 421-5540
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacy | 333600000X | |||
| Clinic Pharmacy | 3336C0002X | 265080 | MN | Primary |
| Community/Retail Pharmacy | 3336C0003X |
Addresses
Primary practice location
530 3Rd St NW
Elk River, MN 55330-1445
Mailing address
2621 Greenhaven Rd Ste 1
Anoka, MN 55303-5566
Phone (763) 441-0764
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2046716 | Other | PK | |
| 606360800 | Medicaid | MN |
Other names 1
- GOODRICH PHARMACY ELK RIVER
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MN
Enrollment records 3
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031211000228 | MN | Part B Supplier - Mass Immunization (Roster Biller Only) | 4082510813 |
4 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Saint Francis, MN; Elk River, MN; Andover, MN; Anoka, MN |
| O20100930054368 | MN | DME Supplier - Pharmacy | 4082510813 | Practice locations: Elk River, MN |
| O20200625002217 | MN | Part B Supplier - Independent Clinical Laboratory | 4082510813 | Practice locations: Elk River, MN |
Other NPIs with the same Medicare PAC ID 4
NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).
Other NPIs on the same Medicare enrollment 3
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 24D2183636 | Goodrich Pharmacy | Certificate of waiver | May 6, 2028 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Goodrich Pharmacy | Surgical Dressings | Accepts assignment |
National Provider Directory
National Provider Directory- Tax ID family
- Goodrich Pharmacy Inc
Other organizations with this tax ID 5
Organizations that report the same tax identification number in the National Provider Directory.
-
- Community/Retail Pharmacy
- Anoka, MN
- NPI 1346244274
-
- Community/Retail Pharmacy
- Andover, MN
- NPI 1619089612
-
- Long Term Care Pharmacy
- Anoka, MN
- NPI 1689517617
-
- Community/Retail Pharmacy
- Saint Francis, MN
- NPI 1891706305
-
- Long Term Care Pharmacy
- Anoka, MN
- NPI 1457937773
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156982400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1688601600000",
"number": "1174635171",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2621 GREENHAVEN RD STE 1",
"city": "ANOKA",
"state": "MN",
"postal_code": "553035566",
"telephone_number": "763-441-0764",
"fax_number": "763-587-4897"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "530 3RD ST NW",
"city": "ELK RIVER",
"state": "MN",
"postal_code": "553301445",
"telephone_number": "763-441-0764",
"fax_number": "763-587-4897"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "GOODRICH PHARMACY, INC.",
"organizational_subpart": "NO",
"enumeration_date": "2006-08-31",
"last_updated": "2023-07-06",
"certification_date": "2023-06-29",
"status": "A",
"authorized_official_last_name": "DAVIS",
"authorized_official_first_name": "STEPHANIE",
"authorized_official_middle_name": "MARIE",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "763-421-5540"
},
"taxonomies": [
{
"code": "333600000X",
"taxonomy_group": "",
"desc": "Pharmacy",
"state": null,
"license": null,
"primary": false
},
{
"code": "3336C0002X",
"taxonomy_group": "",
"desc": "Pharmacy, Clinic Pharmacy",
"state": "MN",
"license": "265080",
"primary": true
},
{
"code": "3336C0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Community/Retail Pharmacy",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PK",
"identifier": "2046716",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "606360800",
"state": "MN"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "GOODRICH PHARMACY ELK RIVER",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "GOODRICH PHARMACY ELK RIVER",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Elk River, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.