1053475020 NPI number — WHITE DRUG CO OF JAMESTOWN INC

Table of content: (NPI 1053475020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053475020 NPI number — WHITE DRUG CO OF JAMESTOWN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE DRUG CO OF JAMESTOWN 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:
Provider Other Organization Name Type Code:
6
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:
1053475020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6701 EVENSTAD DR N STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55369-6013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-513-4300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLEY
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58413-7003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-333-7939
Provider Business Practice Location Address Fax Number:
833-286-8451
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRADER
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
763-513-4300

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHAR673 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2071620 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8535360 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21480WH , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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