Provider Demographics
NPI:1528062312
Name:MANDAN DRUG
Entity type:Organization
Organization Name:MANDAN DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-663-5900
Mailing Address - Street 1:316 W MAIN ST # 398
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:316 W MAIN ST # 398
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3144
Practice Address - Country:US
Practice Address - Phone:701-663-5900
Practice Address - Fax:701-663-5311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
ND67333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3501283OtherOTHER ID NUMBER-COMMERCIAL NUMBER
ND20801Medicaid
ND20801Medicaid