Healthcare Provider Details

I. General information

NPI: 1265084792
Provider Name (Legal Business Name): NUDAK VENTURES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5418 SAINT CROIX TRL
NORTH BRANCH MN
55056-4203
US

IV. Provider business mailing address

PO BOX 640
CONRAD IA
50621-0640
US

V. Phone/Fax

Practice location:
  • Phone: 651-243-5325
  • Fax: 651-243-5324
Mailing address:
  • Phone: 641-366-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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