Basic Information
| Provider Information | |||||||||
| NPI: | 1043260722 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH DAKOTA STATE HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NORTH DAKOTA STATE HOSPITAL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2605 CIRCLE DR | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584016905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012533650 | ||||||||
| FaxNumber: | 7012533035 | ||||||||
| Practice Location | |||||||||
| Address1: | 2605 CIRCLE DR | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584016905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012533650 | ||||||||
| FaxNumber: | 7012533035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ETHERINGTON | ||||||||
| AuthorizedOfficialFirstName: | ROSALIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SUPERINTENDENT | ||||||||
| AuthorizedOfficialTelephone: | 7012533964 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 333600000X | N | Suppliers | Pharmacy | 3336I0012X | 188 | ND | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2071611 | 01 | PK | OTHER | 21476 | 05 | ND | MEDICAID |