=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043260722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH DAKOTA STATE HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 02/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1712 ELMWOOD PLACE
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-269-2979
-----------------------------------------------------
Fax | 701-253-3035
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1712 ELMWOOD PLACE
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-253-3650
-----------------------------------------------------
Fax | 701-253-3035
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT
-----------------------------------------------------
Name | ROSALIE ETHERINGTON
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 701-253-3964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336I0012X
-----------------------------------------------------
Taxonomy Name | Institutional Pharmacy
-----------------------------------------------------
License Number | 188
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------