Provider Demographics
NPI:1639251424
Name:NUDAK VENTURES LLC
Entity Type:Organization
Organization Name:NUDAK VENTURES LLC
Other - Org Name:NUCARA PHARMACY #23
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACQUISITIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-366-3440
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:IA
Mailing Address - Zip Code:50621-0640
Mailing Address - Country:US
Mailing Address - Phone:641-366-3440
Mailing Address - Fax:641-366-3442
Practice Address - Street 1:216 WASHBURNE AVE
Practice Address - Street 2:
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362-1643
Practice Address - Country:US
Practice Address - Phone:320-243-3781
Practice Address - Fax:320-243-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MN2638793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1639251424Medicaid
2134996OtherPK