Provider Demographics
NPI:1487783262
Name:WEST ACRES PHARMACY INC
Entity type:Organization
Organization Name:WEST ACRES PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER AND PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-282-0285
Mailing Address - Street 1:3902 13TH AVE S
Mailing Address - Street 2:STE 3706
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3357
Mailing Address - Country:US
Mailing Address - Phone:701-282-0285
Mailing Address - Fax:701-281-2728
Practice Address - Street 1:3902 13TH AVE S
Practice Address - Street 2:STE 3706
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3357
Practice Address - Country:US
Practice Address - Phone:701-282-0285
Practice Address - Fax:701-281-2728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NDPHAR1133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20857Medicaid
MN878057900Medicaid
2071325OtherPK
ND20857Medicaid