Provider Demographics
NPI:1487923488
Name:BANADIR PHARMACY LLC
Entity type:Organization
Organization Name:BANADIR PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:EDRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-575-1293
Mailing Address - Street 1:1 W LAKE ST STE 195
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3362
Mailing Address - Country:US
Mailing Address - Phone:612-825-1669
Mailing Address - Fax:612-825-1667
Practice Address - Street 1:1 W LAKE ST STE 195
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3362
Practice Address - Country:US
Practice Address - Phone:612-825-1669
Practice Address - Fax:612-825-1667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MN2638043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133164OtherPK