NPIMap

Organization Active NPI

The Duluth Clinic, LTD

Doing business as Essentia Health Lakeside Pharmacy

  • Community/Retail Pharmacy
  • Duluth, MN
National Provider Identifier
1831204940
Registry record updated Feb 28, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
2612425 Issued in MN
Legal business name
THE DULUTH CLINIC, LTD
Doing business as
Essentia Health Lakeside Pharmacy
Practice address
4621 E Superior St
Suite a
Duluth, MN 55804-2338
Phone
(218) 786-3784
Fax
(218) 525-7338
NPI assigned
Aug 20, 2006
Last updated
Feb 28, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
ESSENTIA HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 28, 2024

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

Authorized official

Name
Kevin Boren
Title
VP of Finance
Phone
(218) 786-1009

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X 2612425 MN Primary

Addresses

Primary practice location

4621 E Superior St
Suite a
Duluth, MN 55804-2338

Mailing address

4621 E Superior St
Suite a
Duluth, MN 55804-2338
Phone (218) 786-3784

Other identifiers 4

IdentifierTypeStateIssuer
573OtherMNTHE DULUTH CLINIC, LTD CHAIN CODE
106358800MedicaidMN
24-04642OtherMNNCPDP
33163300MedicaidWI

Other names 1

  • Essentia Health Lakeside Pharmacy Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20151103001283 MN Part B Supplier - Mass Immunization (Roster Biller Only) 2567374283 16 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Virginia, MN; Two Harbors, MN; Silver Bay, MN; International Falls, MN; Hinckley, MN; Hibbing, MN; Hermantown, MN; Grand Rapids, MN…
O20221026002380 MN DME Supplier - Pharmacy 2567374283 Practice locations: Duluth, MN

Other NPIs with the same Medicare PAC ID 24

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

View all 24

Other NPIs on the same Medicare enrollment 16

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 16

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Essentia Health Lakeside Pharmacy4621 E Superior St, Duluth, MN 55804-2338(218) 786-3784 Epoetin|Immunosuppressive Drugs|Infusion Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order) Accepts assignmentParticipating since Oct 24, 2022

National Provider Directory

National Provider Directory
Tax ID family
Deer River Community CL35 organizations share this tax ID, including this one

Other organizations with this tax ID 34

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

View all 34

Member of 1

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

NPI Registry JSON

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

{
    "created_epoch": "1156032000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709078400000",
    "number": "1831204940",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4621 E SUPERIOR ST",
            "address_2": "SUITE A",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558042338",
            "telephone_number": "218-786-3784",
            "fax_number": "218-525-7338"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4621 E SUPERIOR ST",
            "address_2": "SUITE A",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558042338",
            "telephone_number": "218-786-3784",
            "fax_number": "218-525-7338"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE DULUTH CLINIC, LTD",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ESSENTIA HEALTH",
        "enumeration_date": "2006-08-20",
        "last_updated": "2024-02-28",
        "certification_date": "2024-02-28",
        "status": "A",
        "authorized_official_last_name": "BOREN",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_title_or_position": "VP OF FINANCE",
        "authorized_official_telephone_number": "218-786-1009"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MN",
            "license": "2612425",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "THE DULUTH CLINIC, LTD CHAIN CODE",
            "identifier": "573",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "106358800",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "24-04642",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33163300",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Essentia Health Lakeside Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Duluth, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2024; 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.

Verify at the official NPI Registry.