Provider Demographics
NPI:1639111230
Name:CHURCHILL PHARMACY HOLDING INC.
Entity Type:Organization
Organization Name:CHURCHILL PHARMACY HOLDING INC.
Other - Org Name:CHURCHILL PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:701-224-0339
Mailing Address - Street 1:1190 W TURNPIKE AVE STE 2
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1300
Mailing Address - Country:US
Mailing Address - Phone:701-224-0339
Mailing Address - Fax:701-224-0534
Practice Address - Street 1:1190 W TURNPIKE AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1300
Practice Address - Country:US
Practice Address - Phone:701-224-0339
Practice Address - Fax:701-224-0534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
NDPHAR7673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21492Medicaid
2071343OtherPK