Healthcare Provider Details

I. General information

NPI: 1265535389
Provider Name (Legal Business Name): NUDAK VENTURES NORTH DAKOTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 MAIN ST
LISBON ND
58054-4143
US

IV. Provider business mailing address

PO BOX 640
CONRAD IA
50621-0640
US

V. Phone/Fax

Practice location:
  • Phone: 701-683-5282
  • Fax: 701-683-5218
Mailing address:
  • Phone: 641-366-3440
  • Fax: 641-366-3442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHAR829
License Number StateND

VIII. Authorized Official

Name: LORI ANN WILLIS
Title or Position: ACQUISITIONS MANAGER
Credential:
Phone: 641-366-3440