=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669546149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL AVENUE PHARMACY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 CENTRAL AVE N SUITE 101
-----------------------------------------------------
City | VALLEY CITY
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58072-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-845-5280
-----------------------------------------------------
Fax | 701-845-1847
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 CENTRAL AVE N SUITE 101
-----------------------------------------------------
City | VALLEY CITY
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58072-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-845-5280
-----------------------------------------------------
Fax | 701-845-1847
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DOREEN M. SAYLER
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 701-845-5280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 164
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------