Healthcare Provider Details

I. General information

NPI: 1194805796
Provider Name (Legal Business Name): NORTH DAKOTA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NP AVENUE
FARGO ND
58102
US

IV. Provider business mailing address

301 NP AVENUE
FARGO ND
58102
US

V. Phone/Fax

Practice location:
  • Phone: 701-271-1489
  • Fax:
Mailing address:
  • Phone: 701-271-1489
  • Fax: 701-271-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number117
License Number StateND

VIII. Authorized Official

Name: JENNIFER IVERSON
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 701-271-6383