Provider Demographics
NPI:1720020324
Name:YE OLDE MEDICINE SHOPPE
Entity Type:Organization
Organization Name:YE OLDE MEDICINE SHOPPE
Other - Org Name:YE OLDE MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESDIENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-284-7676
Mailing Address - Street 1:503 PARK ST W
Mailing Address - Street 2:
Mailing Address - City:PARK RIVER
Mailing Address - State:ND
Mailing Address - Zip Code:58270-4137
Mailing Address - Country:US
Mailing Address - Phone:701-284-7676
Mailing Address - Fax:701-284-6129
Practice Address - Street 1:503 PARK ST W
Practice Address - Street 2:
Practice Address - City:PARK RIVER
Practice Address - State:ND
Practice Address - Zip Code:58270-4137
Practice Address - Country:US
Practice Address - Phone:701-284-7676
Practice Address - Fax:701-284-6129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
NDPHAR593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20668Medicaid
2071194OtherPK
ND20668Medicaid