Provider Demographics
NPI:1407946338
Name:WALLS MEDICINE CENTER INC
Entity Type:Organization
Organization Name:WALLS MEDICINE CENTER INC
Other - Org Name:WALLS MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-746-0497
Mailing Address - Street 1:708 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4328
Mailing Address - Country:US
Mailing Address - Phone:701-746-0497
Mailing Address - Fax:701-746-7908
Practice Address - Street 1:708 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4328
Practice Address - Country:US
Practice Address - Phone:701-746-0497
Practice Address - Fax:701-746-7908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPHAR139332B00000X
333600000X, 3336C0004X, 3336S0011X
MN2635463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2071242OtherPK
ND20719Medicaid
MN927357300Medicaid
ND20719Medicaid