Provider Demographics
NPI:1043243272
Name:PROFESSIONAL PHARMACY LLC
Entity Type:Organization
Organization Name:PROFESSIONAL PHARMACY LLC
Other - Org Name:PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:MOORE
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:701-224-0339
Mailing Address - Street 1:2425 HILLVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3056
Mailing Address - Country:US
Mailing Address - Phone:701-223-6854
Mailing Address - Fax:701-223-6856
Practice Address - Street 1:3124 COLORADO LANE
Practice Address - Street 2:#400
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503
Practice Address - Country:US
Practice Address - Phone:701-223-6854
Practice Address - Fax:701-223-6856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND624333600000X, 3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21086Medicaid
ND3872590001Medicare NSC