Provider Demographics
NPI:1447273099
Name:ULMER, THOMAS L
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:ULMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:ND
Mailing Address - Zip Code:58436-0780
Mailing Address - Country:US
Mailing Address - Phone:701-349-3390
Mailing Address - Fax:
Practice Address - Street 1:117 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLENDALE
Practice Address - State:ND
Practice Address - Zip Code:58436-0780
Practice Address - Country:US
Practice Address - Phone:701-349-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2011-01-18
Deactivation Date:2009-11-19
Deactivation Code:
Reactivation Date:2011-01-11
Provider Licenses
StateLicense IDTaxonomies
ND3211183500000X
ND173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20043Medicaid
ND0650660001Medicare NSC