NPIMap

Organization Active NPI

Altru Health System

Doing business as Family Medicine Residency Pharmacy

  • Clinic Pharmacy
  • Grand Forks, ND
National Provider Identifier
1144368085
Registry record updated May 23, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic PharmacyTaxonomy code 3336C0002X
License
PHAR477 Issued in ND
Legal business name
ALTRU HEALTH SYSTEM
Doing business as
Family Medicine Residency Pharmacy
Practice address
725 Hamline St
Grand Forks, ND 58203-2819
Phone
(701) 780-6870
Fax
(701) 780-6878
NPI assigned
Feb 2, 2007
Last updated
May 23, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 23, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Derek Goebel
Title
Chief Financial Officer
Phone
(701) 780-1470

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Clinic Pharmacy 3336C0002X PHAR477 ND Primary

Addresses

Primary practice location

725 Hamline St
Grand Forks, ND 58203-2819

Mailing address

725 Hamline St
Grand Forks, ND 58203-2819
Phone (701) 780-6870

Other identifiers 3

IdentifierTypeStateIssuer
2071404OtherPK
574155600MedicaidMN
21082MedicaidND

Other names 1

  • FAMILY MEDICINE RESIDENCY PHARMACY Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100930018292 ND DME Supplier - Pharmacy 1355251604 Practice locations: Grand Forks, ND

Other NPIs with the same Medicare PAC ID 13

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 13

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Family Medicine Residency Pharmacy725 Hamline St, Grand Forks, ND 58203-2819(701) 780-6800 Immunosuppressive Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order) Accepts assignmentParticipating since Oct 29, 2022

National Provider Directory

National Provider Directory
Tax ID family
Altru Clinic Thief River24 organizations share this tax ID, including this one

Other organizations with this tax ID 23

Organizations that report the same tax identification number in the National Provider Directory.

View all 23

Ownership & related parties

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Altru Rehabilitation HospitalGrand Forks, ND, CCN 353027 Hospital 5% Or Greater Direct Ownership Interest (40%) May 24, 2021
Valley Senior Living on ColumbiaGrand Forks, ND, CCN 355067 Skilled nursing facility Operational/Managerial Control
Adp of the SNF		 Jun 1, 1994
May 21, 2025
Woodside VillageGrand Forks, ND, CCN 355112 Skilled nursing facility Operational/Managerial Control
Adp of the SNF		 Jun 1, 1994
May 21, 2025
Altru's Home HealthGrand Forks, ND, CCN 357014 Home health agency 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1997

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170374400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1716422400000",
    "number": "1144368085",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "725 HAMLINE ST",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "582032819",
            "telephone_number": "701-780-6870",
            "fax_number": "701-780-6878"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "725 HAMLINE ST",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "582032819",
            "telephone_number": "701-780-6870",
            "fax_number": "701-780-6878"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ALTRU HEALTH SYSTEM",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-02",
        "last_updated": "2024-05-23",
        "certification_date": "2024-05-23",
        "status": "A",
        "authorized_official_last_name": "GOEBEL",
        "authorized_official_first_name": "DEREK",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "701-780-1470"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Clinic Pharmacy",
            "state": "ND",
            "license": "PHAR477",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2071404",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "574155600",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "21082",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "FAMILY MEDICINE RESIDENCY PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grand Forks, ND

Sources for this page

Verify at the official NPI Registry.