Provider Demographics
NPI:1508972936
Name:KILLDEER PHARMACY INC.
Entity Type:Organization
Organization Name:KILLDEER PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-764-5093
Mailing Address - Street 1:14 SOUTH CENTRAL AVE
Mailing Address - Street 2:PO BOX 745
Mailing Address - City:KILLDEER
Mailing Address - State:ND
Mailing Address - Zip Code:58640
Mailing Address - Country:US
Mailing Address - Phone:701-764-5093
Mailing Address - Fax:701-764-5094
Practice Address - Street 1:14 SOUTH CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KILLDEER
Practice Address - State:ND
Practice Address - Zip Code:58640
Practice Address - Country:US
Practice Address - Phone:701-764-5093
Practice Address - Fax:701-764-5094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21196Medicaid
ND3503744OtherNCPDP NUMBER
1125700001Medicare NSC