Provider Demographics
NPI:1346392149
Name:BETHANY PHARMACY , INC.
Entity Type:Organization
Organization Name:BETHANY PHARMACY , INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-239-3543
Mailing Address - Street 1:201 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1775
Mailing Address - Country:US
Mailing Address - Phone:701-239-3543
Mailing Address - Fax:701-239-3547
Practice Address - Street 1:201 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1775
Practice Address - Country:US
Practice Address - Phone:701-239-3543
Practice Address - Fax:701-239-3547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND161835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21120Medicaid
ND1052480001Medicare ID - Type Unspecified