Healthcare Provider Details

I. General information

NPI: 1811939416
Provider Name (Legal Business Name): NORTH DAKOTA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 CENTENNIAL BLVD
FARGO ND
58102
US

IV. Provider business mailing address

NDSU DEPARTMENT 5150 PO BOX 6050
FARGO ND
58108-6050
US

V. Phone/Fax

Practice location:
  • Phone: 701-231-7332
  • Fax: 701-231-6132
Mailing address:
  • Phone: 701-231-7332
  • Fax: 701-231-6132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPHAR168
License Number StateND

VIII. Authorized Official

Name: ALICIA FITZ
Title or Position: PHARMACIST IN CHARGE
Credential: PHARM D
Phone: 701-231-7332