Provider Demographics
NPI:1144231705
Name:THOMAS MOE
Entity Type:Organization
Organization Name:THOMAS MOE
Other - Org Name:NORTHBROOK DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-258-1412
Mailing Address - Street 1:1929 N WASHINGTON ST
Mailing Address - Street 2:STE C
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1616
Mailing Address - Country:US
Mailing Address - Phone:701-258-1412
Mailing Address - Fax:701-258-1413
Practice Address - Street 1:1929 N WASHINGTON ST
Practice Address - Street 2:STE C
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1616
Practice Address - Country:US
Practice Address - Phone:701-258-1412
Practice Address - Fax:701-258-1413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ND203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20617Medicaid
3502033OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3502033OtherNCPDP PROVIDER IDENTIFICATION NUMBER