Healthcare Provider Details

I. General information

NPI: 1063140010
Provider Name (Legal Business Name): MS4 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4476 31ST AVE S STE 105
FARGO ND
58104-4532
US

IV. Provider business mailing address

4476 31ST AVE S STE 105
FARGO ND
58104-4532
US

V. Phone/Fax

Practice location:
  • Phone: 701-639-6969
  • Fax:
Mailing address:
  • Phone: 701-639-6969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LANELL HAGEN
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 701-293-0221