Healthcare Provider Details

I. General information

NPI: 1346392149
Provider Name (Legal Business Name): BETHANY PHARMACY , INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 UNIVERSITY DR S
FARGO ND
58103-1775
US

IV. Provider business mailing address

201 UNIVERSITY DR S
FARGO ND
58103-1775
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3543
  • Fax: 701-239-3547
Mailing address:
  • Phone: 701-239-3543
  • Fax: 701-239-3547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number16
License Number StateND

VIII. Authorized Official

Name: MS. KAY M LARSON
Title or Position: OWNER
Credential: RPH
Phone: 701-239-3543