Provider Demographics
NPI:1881791721
Name:NORTH PRARIE PHARMACIES LLC
Entity type:Organization
Organization Name:NORTH PRARIE PHARMACIES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-746-0497
Mailing Address - Street 1:4731 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7269
Mailing Address - Country:US
Mailing Address - Phone:701-373-0325
Mailing Address - Fax:701-373-0327
Practice Address - Street 1:4731 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7269
Practice Address - Country:US
Practice Address - Phone:701-373-0325
Practice Address - Fax:701-373-0327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ND6043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN640126100Medicaid
ND21448Medicaid
2071598OtherPK