Provider Demographics
NPI:1790004182
Name:YE OLDE MEDICINE SHOPPE INC
Entity Type:Organization
Organization Name:YE OLDE MEDICINE SHOPPE INC
Other - Org Name:DRAYTON DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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 1:104 E HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:DRAYTON
Mailing Address - State:ND
Mailing Address - Zip Code:58225-4804
Mailing Address - Country:US
Mailing Address - Phone:701-454-3831
Mailing Address - Fax:701-454-3338
Practice Address - Street 1:104 E HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:DRAYTON
Practice Address - State:ND
Practice Address - Zip Code:58225-4804
Practice Address - Country:US
Practice Address - Phone:701-454-3831
Practice Address - Fax:701-454-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NDPHAR3623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125584OtherPK
ND21549Medicaid
ND21549Medicaid