Healthcare Provider Details

I. General information

NPI: 1053414565
Provider Name (Legal Business Name): NUDAK VENTURES NORTH DAKOTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 CENTRAL AVE
WALHALLA ND
58282-4017
US

IV. Provider business mailing address

PO BOX 640
CONRAD IA
50621-0640
US

V. Phone/Fax

Practice location:
  • Phone: 701-549-2661
  • Fax: 701-549-2664
Mailing address:
  • Phone: 641-366-3440
  • Fax: 641-366-3442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number88
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

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