1306935911 NPI number — WHITE DRUG CO OF JAMESTOWN INC

Table of content: (NPI 1306935911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306935911 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:
1306935911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2024
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:
1015 S BROADWAY STE 3
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
MINOT
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58701-4667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-852-4181
Provider Business Practice Location Address Fax Number:
701-839-6019
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FROISTAD
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSING COORDINATOR
Authorized Official Telephone Number:
763-513-4377

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: PHAR74 , 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: 1455354 RX , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2071201 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1306935911 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1455802 DME , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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