1548627631 NPI number — CROSBY DRUG LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548627631 NPI number — CROSBY DRUG LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSBY DRUG LLC
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:
1548627631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 888
Provider Second Line Business Mailing Address:
P.O. BOX 888
Provider Business Mailing Address City Name:
CROSBY
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58730-0861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-965-6671
Provider Business Mailing Address Fax Number:
701-965-6849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 MAIN STREET NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROSBY
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58730-0050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-965-6671
Provider Business Practice Location Address Fax Number:
701-965-6849
Provider Enumeration Date:
01/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GRATZ
Authorized Official First Name:
GABRIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER/OWNER
Authorized Official Telephone Number:
701-572-7979

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHAR949 , 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: 1466938 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2158067 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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