Healthcare Provider Details

I. General information

NPI: 1750729638
Provider Name (Legal Business Name): ALEXIS DAWN WALDOCH PHARM.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N BROADWAY ST
LINTON ND
58552-7018
US

IV. Provider business mailing address

121 N BROADWAY ST P.O BOX 760
LINTON ND
58552-7018
US

V. Phone/Fax

Practice location:
  • Phone: 701-254-5432
  • Fax: 701-254-4876
Mailing address:
  • Phone: 701-254-5432
  • Fax: 701-254-4876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5403
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: