Healthcare Provider Details

I. General information

NPI: 1477212116
Provider Name (Legal Business Name): MS4 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 JACKS WAY STE 101
HORACE ND
58047-2802
US

IV. Provider business mailing address

8001 JACKS WAY STE 101
HORACE ND
58047-2802
US

V. Phone/Fax

Practice location:
  • Phone: 701-997-5337
  • Fax: 701-997-5338
Mailing address:
  • Phone: 701-997-5337
  • Fax: 701-997-5338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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