Provider Demographics
NPI:1043260722
Name:NORTH DAKOTA STATE HOSPITAL
Entity Type:Organization
Organization Name:NORTH DAKOTA STATE HOSPITAL
Other - Org Name:NORTH DAKOTA STATE HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ETHERINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:701-253-3964
Mailing Address - Street 1:1712 ELMWOOD PLACE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401
Mailing Address - Country:US
Mailing Address - Phone:701-253-3650
Mailing Address - Fax:701-253-3035
Practice Address - Street 1:1712 ELMWOOD PLACE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401
Practice Address - Country:US
Practice Address - Phone:701-269-2979
Practice Address - Fax:701-253-3035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
ND1883336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2071611OtherPK
ND21476Medicaid