Provider Demographics
NPI:1588021943
Name:DAKOTA CLINIC PHARMACY LLC
Entity Type:Organization
Organization Name:DAKOTA CLINIC PHARMACY LLC
Other - Org Name:DAKOTA CLINIC PHARMACY ON 32ND AVENUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST, CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:701-364-3450
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-364-3450
Mailing Address - Fax:701-364-3382
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-7800
Practice Address - Fax:701-364-7808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NDPHAR3133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158673OtherPK