Provider Demographics
NPI:1811939416
Name:NORTH DAKOTA STATE UNIVERSITY
Entity type:Organization
Organization Name:NORTH DAKOTA STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:701-231-7332
Mailing Address - Street 1:NDSU DEPARTMENT 5150
Mailing Address - Street 2:PO BOX 6050
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6050
Mailing Address - Country:US
Mailing Address - Phone:701-231-7332
Mailing Address - Fax:701-231-6132
Practice Address - Street 1:1707 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-231-7332
Practice Address - Fax:701-231-6132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPHAR1683336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21162NDMedicaid
2070818OtherPK