Provider Demographics
NPI:1053414565
Name:NUDAK VENTURES NORTH DAKOTA, LLC
Entity type:Organization
Organization Name:NUDAK VENTURES NORTH DAKOTA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACQUISITIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-366-3440
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:IA
Mailing Address - Zip Code:50621-0640
Mailing Address - Country:US
Mailing Address - Phone:641-366-3440
Mailing Address - Fax:641-366-3442
Practice Address - Street 1:1102 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WALHALLA
Practice Address - State:ND
Practice Address - Zip Code:58282-4017
Practice Address - Country:US
Practice Address - Phone:701-549-2661
Practice Address - Fax:701-549-2664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND883336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND3503617OtherNCPDP NUMBER
ND21144Medicaid
ND21144Medicaid