Provider Demographics
NPI:1750533709
Name:ST. ALEXIUS COMMUNITY PHARMACY
Entity type:Organization
Organization Name:ST. ALEXIUS COMMUNITY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, OUTPATIENT PHARMACY SERV
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DETWILLER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-530-6926
Mailing Address - Street 1:900 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4520
Mailing Address - Country:US
Mailing Address - Phone:701-530-6906
Mailing Address - Fax:701-530-6907
Practice Address - Street 1:900 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4520
Practice Address - Country:US
Practice Address - Phone:701-530-6906
Practice Address - Fax:701-530-6907
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST ALEXIUS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-21
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND190332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND000021438Medicaid