Provider Demographics
NPI:1346468154
Name:TIOGA MEDICAL CENTER PHARMACY
Entity Type:Organization
Organization Name:TIOGA MEDICAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:K
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-664-3305
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:TIOGA
Mailing Address - State:ND
Mailing Address - Zip Code:58852-0159
Mailing Address - Country:US
Mailing Address - Phone:701-664-3305
Mailing Address - Fax:701-664-2240
Practice Address - Street 1:810 N WELO ST
Practice Address - Street 2:
Practice Address - City:TIOGA
Practice Address - State:ND
Practice Address - Zip Code:58852-7157
Practice Address - Country:US
Practice Address - Phone:701-664-3305
Practice Address - Fax:701-664-2240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2033336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21109Medicaid