Healthcare Provider Details

I. General information

NPI: 1780768812
Provider Name (Legal Business Name): INTERSTATE RETAIL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 MAIN ST
WILLISTON ND
58801-5303
US

IV. Provider business mailing address

317 MAIN ST
WILLISTON ND
58801-5303
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-6721
  • Fax: 701-572-6723
Mailing address:
  • Phone: 701-572-6721
  • Fax: 701-572-6723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number61
License Number StateND

VIII. Authorized Official

Name: BRIAN BOLINSKE
Title or Position: OWNER
Credential: RPH
Phone: 701-572-6721