Provider Demographics
NPI:1962436113
Name:GRAND FORKS CLINIC PHARMACY
Entity type:Organization
Organization Name:GRAND FORKS CLINIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:FINSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-772-4875
Mailing Address - Street 1:1000 S COLUMBIA RD
Mailing Address - Street 2:P.O. BOX 13115
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4032
Mailing Address - Country:US
Mailing Address - Phone:701-772-4875
Mailing Address - Fax:701-780-6577
Practice Address - Street 1:1000 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4032
Practice Address - Country:US
Practice Address - Phone:701-772-4875
Practice Address - Fax:701-780-6577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20066Medicaid
ND20066Medicaid