Healthcare Provider Details

I. General information

NPI: 1588879167
Provider Name (Legal Business Name): NUDAK VENTURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W VALLETTE ST
ELMHURST IL
60126-4419
US

IV. Provider business mailing address

PO BOX 640
CONRAD IA
50621-0640
US

V. Phone/Fax

Practice location:
  • Phone: 630-834-1260
  • Fax: 630-834-3166
Mailing address:
  • Phone: 641-366-3440
  • Fax: 641-366-3442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number54.018039
License Number StateIL

VIII. Authorized Official

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