Healthcare Provider Details

I. General information

NPI: 1912954165
Provider Name (Legal Business Name): MEDICAL PHARMACY SOUTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4151 45TH ST S
FARGO ND
58104-4312
US

IV. Provider business mailing address

4151 45TH ST S
FARGO ND
58104-4312
US

V. Phone/Fax

Practice location:
  • Phone: 701-282-8075
  • Fax: 701-282-8594
Mailing address:
  • Phone: 701-282-8075
  • Fax: 701-282-8594

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 Number408
License Number StateND

VIII. Authorized Official

Name: LANA KIRSCHENMANN
Title or Position: PRESIDENT
Credential: PHARM D
Phone: 701-282-8075