Provider Demographics
NPI:1710977897
Name:SOUTHTOWN ECONODRUG, INC.
Entity Type:Organization
Organization Name:SOUTHTOWN ECONODRUG, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-642-2336
Mailing Address - Street 1:387 11TH ST S
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4653
Mailing Address - Country:US
Mailing Address - Phone:701-642-2336
Mailing Address - Fax:701-642-1470
Practice Address - Street 1:387 11TH ST S
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4653
Practice Address - Country:US
Practice Address - Phone:701-642-2336
Practice Address - Fax:701-642-1470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21128Medicaid
SD9167120Medicaid
MN091062700Medicaid
ND0776850001OtherMEDICARE PART B NSC#
ND0776850001Medicare NSC
ND21128Medicaid