=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124039763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NUDAK VENTURES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 05/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 BROAD ST
-----------------------------------------------------
City | STORY CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50248-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-733-2233
-----------------------------------------------------
Fax | 515-733-2366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 640
-----------------------------------------------------
City | CONRAD
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50621-0640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-733-2233
-----------------------------------------------------
Fax | 515-733-2366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DELEGATED OFFICIAL
-----------------------------------------------------
Name | LORI WILLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 641-366-3440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 78
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------