Provider Demographics
NPI:1811014160
Name:JAMES RIVER CORRECTIONAL CENTER PHARMACY
Entity Type:Organization
Organization Name:JAMES RIVER CORRECTIONAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST II
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:701-253-3612
Mailing Address - Street 1:2521 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-6904
Mailing Address - Country:US
Mailing Address - Phone:701-253-3612
Mailing Address - Fax:701-253-3666
Practice Address - Street 1:2521 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-6904
Practice Address - Country:US
Practice Address - Phone:701-253-3612
Practice Address - Fax:701-253-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND584273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit