=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295778082
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEULAH DRUG COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 09/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 147 W MAIN ST
-----------------------------------------------------
City | BEULAH
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58523-6969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-873-5215
-----------------------------------------------------
Fax | 701-873-4908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 99
-----------------------------------------------------
City | BEULAH
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58523-0099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-873-5215
-----------------------------------------------------
Fax | 701-873-4908
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PIC
-----------------------------------------------------
Name | WYATT ELDON MARTENSON
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 701-873-5215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHAR145
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------