1962787440 NPI number — AVERA MCKENNAN

Table of content: (NPI 1962787440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962787440 NPI number — AVERA MCKENNAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA MCKENNAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AVERA 69TH STREET PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962787440
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4400 W 69TH ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57108-8170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-5948
Provider Business Mailing Address Fax Number:
605-322-5949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 W 69TH ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57108-8170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-5948
Provider Business Practice Location Address Fax Number:
605-322-5949
Provider Enumeration Date:
10/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MUTCHLER
Authorized Official First Name:
DARREL
Authorized Official Middle Name:
Authorized Official Title or Position:
RETAIL PHARMACY MANAGER
Authorized Official Telephone Number:
605-322-8331

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  4574 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 333600000X , with the licence number: 100-1967 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 1020 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054.019698 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 264333 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2132318 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1962787440 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1962787440 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1962787440 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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