Healthcare Provider Details

I. General information

NPI: 1619151206
Provider Name (Legal Business Name): GLEN ULLIN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 S MAIN ST
GLEN ULLIN ND
58631-7101
US

IV. Provider business mailing address

PO BOX 636
GLEN ULLIN ND
58631-0636
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 TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number789
License Number StateND

VIII. Authorized Official

Name: DR. DANIEL MOORE CHURCHILL
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 701-224-0339