Provider Demographics
NPI:1205923406
Name:WESTERN DAKOTA PHARMACY, INC.
Entity type:Organization
Organization Name:WESTERN DAKOTA PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GRATZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-572-7797
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-0640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1102 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4233
Practice Address - Country:US
Practice Address - Phone:701-572-7797
Practice Address - Fax:701-572-0937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND51333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3501930OtherOTHER ID NUMBER-COMMERCIAL NUMBER
ND20176Medicaid