Healthcare Provider Details

I. General information

NPI: 1972000768
Provider Name (Legal Business Name): NORTH DAKOTA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 9TH AVE S STE D
FARGO ND
58103-2101
US

IV. Provider business mailing address

4025 9TH AVE S STE D
FARGO ND
58103-2101
US

V. Phone/Fax

Practice location:
  • Phone: 701-551-2446
  • Fax: 701-364-9938
Mailing address:
  • Phone: 701-551-2446
  • Fax: 701-364-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPHAR252
License Number StateND

VIII. Authorized Official

Name: NICOLE DANIEL
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 701-551-2446