Provider Demographics
NPI:1265548101
Name:CHASE DRUG STORE INC
Entity type:Organization
Organization Name:CHASE DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-462-8174
Mailing Address - Street 1:703 MAIN AVE
Mailing Address - Street 2:PO BOX 400
Mailing Address - City:WASHBURN
Mailing Address - State:ND
Mailing Address - Zip Code:58577
Mailing Address - Country:US
Mailing Address - Phone:701-462-8174
Mailing Address - Fax:701-462-3597
Practice Address - Street 1:703 MAIN AVENUE
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:ND
Practice Address - Zip Code:58577-0400
Practice Address - Country:US
Practice Address - Phone:701-462-8174
Practice Address - Fax:701-462-3597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
ND160333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
70482OtherBCBS OF ND
ND20164Medicaid
ND20164Medicaid