Provider Demographics
NPI:1831559921
Name:ELLENDALE PHARMACY INC
Entity type:Organization
Organization Name:ELLENDALE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ULMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-349-3390
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:ND
Mailing Address - Zip Code:58436-0780
Mailing Address - Country:US
Mailing Address - Phone:701-349-3390
Mailing Address - Fax:701-349-3052
Practice Address - Street 1:117 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLENDALE
Practice Address - State:ND
Practice Address - Zip Code:58436-7101
Practice Address - Country:US
Practice Address - Phone:701-349-3390
Practice Address - Fax:701-349-3052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPHAR5353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158114OtherPK
2158114OtherPK