Healthcare Provider Details

I. General information

NPI: 1508972936
Provider Name (Legal Business Name): KILLDEER PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 12/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 SOUTH CENTRAL AVE
KILLDEER ND
58640
US

IV. Provider business mailing address

14 SOUTH CENTRAL AVE PO BOX 745
KILLDEER ND
58640
US

V. Phone/Fax

Practice location:
  • Phone: 701-764-5093
  • Fax: 701-764-5094
Mailing address:
  • Phone: 701-764-5093
  • Fax: 701-764-5094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number58
License Number StateND

VIII. Authorized Official

Name: MR. JODY A DOE
Title or Position: OWNER
Credential: RPH
Phone: 701-764-5093