Provider Demographics
NPI:1619151206
Name:GLEN ULLIN PHARMACY LLC
Entity Type:Organization
Organization Name:GLEN ULLIN PHARMACY LLC
Other - Org Name:GLEN ULLIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:MOORE
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:701-224-0339
Mailing Address - Street 1:PO BOX 636
Mailing Address - Street 2:
Mailing Address - City:GLEN ULLIN
Mailing Address - State:ND
Mailing Address - Zip Code:58631-0636
Mailing Address - Country:US
Mailing Address - Phone:701-348-3303
Mailing Address - Fax:701-348-3913
Practice Address - Street 1:113 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GLEN ULLIN
Practice Address - State:ND
Practice Address - Zip Code:58631-7101
Practice Address - Country:US
Practice Address - Phone:701-348-3303
Practice Address - Fax:701-348-3913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7893336C0003X, 3336C0003X
3336L0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153034OtherPK
4460030001Medicare NSC