Provider Demographics
NPI:1871829028
Name:ALTRU CLINIC PHARMACY - FAMILY MEDICINE CENTER INC
Entity type:Organization
Organization Name:ALTRU CLINIC PHARMACY - FAMILY MEDICINE CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HULST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-795-2020
Mailing Address - Street 1:1380 S COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4059
Mailing Address - Country:US
Mailing Address - Phone:701-795-2020
Mailing Address - Fax:701-795-2019
Practice Address - Street 1:1380 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4059
Practice Address - Country:US
Practice Address - Phone:701-795-2020
Practice Address - Fax:701-795-2019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPHAR959333600000X
MN2645253336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122317OtherPK
MN1871829028Medicaid
ND1457480Medicaid
MN1871829028Medicaid