Healthcare Provider Details

I. General information

NPI: 1295778082
Provider Name (Legal Business Name): BEULAH DRUG COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 W MAIN ST
BEULAH ND
58523-6969
US

IV. Provider business mailing address

PO BOX 99
BEULAH ND
58523-0099
US

V. Phone/Fax

Practice location:
  • Phone: 701-873-5215
  • Fax: 701-873-4908
Mailing address:
  • Phone: 701-873-5215
  • Fax: 701-873-4908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHAR145
License Number StateND

VIII. Authorized Official

Name: WYATT ELDON MARTENSON
Title or Position: OWNER/PIC
Credential: PHARMD
Phone: 701-873-5215