Provider Demographics
NPI:1336472505
Name:MIDWEST DRUG DISTRIBUTION INC
Entity Type:Organization
Organization Name:MIDWEST DRUG DISTRIBUTION INC
Other - Org Name:MIDWEST PHARMACY OF FARGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST N CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-373-8504
Mailing Address - Street 1:4153 12 TH AVE. NORTH SUITE B
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102
Mailing Address - Country:US
Mailing Address - Phone:701-373-8504
Mailing Address - Fax:
Practice Address - Street 1:4153 12 TH AVE. NORTH SUITE B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-373-8504
Practice Address - Fax:701-373-8506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-04
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND951333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
6331580001Medicare NSC