Healthcare Provider Details

I. General information

NPI: 1740558634
Provider Name (Legal Business Name): NORTHERN ITASCA HOSPITAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 PINE TREE DRIVE
BIGFORK MN
56628-0258
US

IV. Provider business mailing address

PO BOX 258 258 PINE TREE DRIVE
BIGFORK MN
56628-0258
US

V. Phone/Fax

Practice location:
  • Phone: 218-743-4225
  • Fax: 218-743-4313
Mailing address:
  • Phone: 218-743-4225
  • Fax: 218-743-4313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number261307
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number261307
License Number StateMN

VIII. Authorized Official

Name: MR. HAROLD DANIEL ODEGAARD
Title or Position: CEO
Credential:
Phone: 218-743-4115