Provider Demographics
NPI:1790762318
Name:UNIVERSITY OF NORTH DAKOTA
Entity Type:Organization
Organization Name:UNIVERSITY OF NORTH DAKOTA
Other - Org Name:UNIVERSITY OF NORTH DAKOTA STUDENT HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHRGE
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-777-3965
Mailing Address - Street 1:MCCANNEL HALL RM 100
Mailing Address - Street 2:2891 2ND AVE N STOP 9038
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202
Mailing Address - Country:US
Mailing Address - Phone:701-777-3965
Mailing Address - Fax:701-777-6129
Practice Address - Street 1:2891 2ND AVE N STOP 9038
Practice Address - Street 2:MCCANNEL HALL RM 100
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-9038
Practice Address - Country:US
Practice Address - Phone:701-777-3965
Practice Address - Fax:701-777-6129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ND1163336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2071244OtherPK
ND1170540Medicaid
MN1740130Medicaid