1972000768 NPI number — NORTH DAKOTA STATE UNIVERSITY

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 1972000768 NPI number — NORTH DAKOTA STATE UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH DAKOTA STATE UNIVERSITY
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:
FAMILY HEALTHCARE PHARMACY SOUTH
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:
1972000768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 NP AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58102-4835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-271-6390
Provider Business Mailing Address Fax Number:
701-271-3345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4025 9TH AVE S STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-2101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-551-2446
Provider Business Practice Location Address Fax Number:
701-364-9938
Provider Enumeration Date:
04/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DANIEL
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
701-551-2446

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  PHAR252 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PHAR252 . This is a "STATE PHARMACY LICENSE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 1475078 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1972000768 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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