Provider Demographics
NPI:1649329632
Name:NORTH DAKOTA DOCR PHARMACY
Entity type:Organization
Organization Name:NORTH DAKOTA DOCR PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-328-6389
Mailing Address - Street 1:PO BOX 5521
Mailing Address - Street 2:3100 RAILROAD AVENUE
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5521
Mailing Address - Country:US
Mailing Address - Phone:701-328-6389
Mailing Address - Fax:701-328-6391
Practice Address - Street 1:3100 RAILROAD AVENUE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58506-5521
Practice Address - Country:US
Practice Address - Phone:701-328-6389
Practice Address - Fax:701-328-6391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3397183500000X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty