Provider Demographics
NPI:1912954165
Name:MEDICAL PHARMACY SOUTH INC
Entity Type:Organization
Organization Name:MEDICAL PHARMACY SOUTH INC
Other - Org Name:MEDICAL PHARMACY SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRSCHENMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:701-282-8075
Mailing Address - Street 1:4151 45TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4312
Mailing Address - Country:US
Mailing Address - Phone:701-282-8075
Mailing Address - Fax:701-282-8594
Practice Address - Street 1:4151 45TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4312
Practice Address - Country:US
Practice Address - Phone:701-282-8075
Practice Address - Fax:701-282-8594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ND4083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1451212Medicaid
2071612OtherPK
MN350035700Medicaid
ND21463Medicaid