Provider Demographics
NPI:1740558634
Name:NORTHERN ITASCA HOSPITAL PHARMACY
Entity Type:Organization
Organization Name:NORTHERN ITASCA HOSPITAL PHARMACY
Other - Org Name:BIGFORK VALLEY HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:ODEGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-743-4115
Mailing Address - Street 1:PO BOX 258
Mailing Address - Street 2:258 PINE TREE DRIVE
Mailing Address - City:BIGFORK
Mailing Address - State:MN
Mailing Address - Zip Code:56628-0258
Mailing Address - Country:US
Mailing Address - Phone:218-743-4225
Mailing Address - Fax:218-743-4313
Practice Address - Street 1:258 PINE TREE DRIVE
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MN
Practice Address - Zip Code:56628-0258
Practice Address - Country:US
Practice Address - Phone:218-743-4225
Practice Address - Fax:218-743-4313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2613073336I0012X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN261307OtherLICENSE
MN2421864OtherNCPDP
MN2421864OtherNCPDP