Healthcare Provider Details

I. General information

NPI: 1841363207
Provider Name (Legal Business Name): DALE CLYDE SEASE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 SOUTH MAIN ST
GLEN ULLIN ND
58631-0670
US

IV. Provider business mailing address

PO BOX 670 113 SOUTH MAIN ST
GLEN ULLIN ND
58631-0670
US

V. Phone/Fax

Practice location:
  • Phone: 701-348-3303
  • Fax: 701-348-3913
Mailing address:
  • Phone: 701-348-3303
  • Fax: 701-348-3913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3203
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: