Provider Demographics
NPI:1972000768
Name:NORTH DAKOTA STATE UNIVERSITY
Entity Type:Organization
Organization Name:NORTH DAKOTA STATE UNIVERSITY
Other - Org Name:FAMILY HEALTHCARE PHARMACY SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-551-2446
Mailing Address - Street 1:301 NP AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4835
Mailing Address - Country:US
Mailing Address - Phone:701-271-6390
Mailing Address - Fax:701-271-3345
Practice Address - Street 1:4025 9TH AVE S STE D
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2101
Practice Address - Country:US
Practice Address - Phone:701-551-2446
Practice Address - Fax:701-364-9938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH DAKOTA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-09
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPHAR2523336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDPHAR252OtherSTATE PHARMACY LICENSE
ND1475078Medicaid
MN1972000768Medicaid