Healthcare Provider Details

I. General information

NPI: 1346468154
Provider Name (Legal Business Name): TIOGA MEDICAL CENTER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N WELO ST
TIOGA ND
58852-7157
US

IV. Provider business mailing address

PO BOX 159
TIOGA ND
58852-0159
US

V. Phone/Fax

Practice location:
  • Phone: 701-664-3305
  • Fax: 701-664-2240
Mailing address:
  • Phone: 701-664-3305
  • Fax: 701-664-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number203
License Number StateND

VIII. Authorized Official

Name: RANDALL K PEDERSON
Title or Position: PRESIDENT CEO
Credential:
Phone: 701-664-3305