Healthcare Provider Details

I. General information

NPI: 1457601254
Provider Name (Legal Business Name): NUDAK VENTURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 S GRANT RD
CARROLL IA
51401-3102
US

IV. Provider business mailing address

PO BOX 640
CONRAD IA
50621-0640
US

V. Phone/Fax

Practice location:
  • Phone: 712-792-3833
  • Fax: 712-792-4019
Mailing address:
  • Phone: 641-366-3440
  • Fax: 641-366-3442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1424
License Number StateIA

VIII. Authorized Official

Name: LORI WILLIS
Title or Position: ACQUISITIONS MANAGER
Credential:
Phone: 641-366-3440