Provider Demographics
NPI:1336283928
Name:ST ALEXIUS MEDICAL CENTER
Entity Type:Organization
Organization Name:ST ALEXIUS MEDICAL CENTER
Other - Org Name:ST. ALEXIUS COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:DETWILLER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-530-6926
Mailing Address - Street 1:900 E BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-530-6906
Mailing Address - Fax:701-530-8842
Practice Address - Street 1:900 E BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-530-6906
Practice Address - Fax:701-530-8842
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST ALEXIUS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-16
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC190OtherND STATELICENSE
NC190OtherND STATELICENSE