Provider Demographics
NPI:1093134017
Name:ST. ALEXIUS MANDAN PHARMACY, LLC
Entity Type:Organization
Organization Name:ST. ALEXIUS MANDAN PHARMACY, LLC
Other - Org Name:ST. ALEXIUS MANDAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-214-1868
Mailing Address - Street 1:2500 SUNSET DRIVE NW, SUITE 2
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554
Mailing Address - Country:US
Mailing Address - Phone:701-530-3750
Mailing Address - Fax:701-530-3788
Practice Address - Street 1:2500 SUNSET DRIVE NW, SUITE 2
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554
Practice Address - Country:US
Practice Address - Phone:701-530-3750
Practice Address - Fax:701-530-3788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-08
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336C0004X
ND7933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144895OtherPK