Healthcare Provider Details

I. General information

NPI: 1487783262
Provider Name (Legal Business Name): WEST ACRES PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 13TH AVE S STE 3706
FARGO ND
58103-3357
US

IV. Provider business mailing address

3902 13TH AVE S STE 3706
FARGO ND
58103-3357
US

V. Phone/Fax

Practice location:
  • Phone: 701-282-0285
  • Fax: 701-281-2728
Mailing address:
  • Phone: 701-282-0285
  • Fax: 701-281-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHAR113
License Number StateND

VIII. Authorized Official

Name: RODNEY LOBERG
Title or Position: MANAGER AND PARTNER
Credential:
Phone: 701-282-0285