Provider Demographics
NPI:1548627631
Name:CROSBY DRUG LLC
Entity type:Organization
Organization Name:CROSBY DRUG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRATZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:701-572-7979
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:P.O. BOX 888
Mailing Address - City:CROSBY
Mailing Address - State:ND
Mailing Address - Zip Code:58730-0861
Mailing Address - Country:US
Mailing Address - Phone:701-965-6671
Mailing Address - Fax:701-965-6849
Practice Address - Street 1:30 MAIN STREET NORTH
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:ND
Practice Address - Zip Code:58730-0050
Practice Address - Country:US
Practice Address - Phone:701-965-6671
Practice Address - Fax:701-965-6849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
NDPHAR9493336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1466938Medicaid
2158067OtherPK