1376632067 NPI number — WALLS ALTRU PHARMACY INC

Table of content: KAREN JACKSON M.A., LMFT (NPI 1326378456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376632067 NPI number — WALLS ALTRU PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLS ALTRU PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WALLS HEALTH MART PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376632067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4440 S WASHINGTON ST
Provider Second Line Business Mailing Address:
STE 101D
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-7245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-732-2900
Provider Business Mailing Address Fax Number:
701-732-2909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4440 S WASHINGTON ST
Provider Second Line Business Practice Location Address:
STE 101D
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-7245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-732-2900
Provider Business Practice Location Address Fax Number:
701-732-2909
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
701-746-0497

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  264179 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X , with the licence number: PHAR815 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336I0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21479 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 734967100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2071617 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com