Provider Demographics
NPI:1588770440
Name:KILLDEER PHAMRACY INC
Entity type:Organization
Organization Name:KILLDEER PHAMRACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-579-4130
Mailing Address - Street 1:713 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEW ENGLAND
Mailing Address - State:ND
Mailing Address - Zip Code:58647
Mailing Address - Country:US
Mailing Address - Phone:701-579-4130
Mailing Address - Fax:701-579-4899
Practice Address - Street 1:713 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEW ENGLAND
Practice Address - State:ND
Practice Address - Zip Code:58647
Practice Address - Country:US
Practice Address - Phone:701-579-4130
Practice Address - Fax:701-579-4899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21388Medicaid
ND1125700002Medicare NSC