Healthcare Provider Details

I. General information

NPI: 1437203882
Provider Name (Legal Business Name): SHAKOPEE MDEWAKANTON SIOUX COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15045 MYSTIC LAKE DR NW
PRIOR LAKE MN
55372-9011
US

IV. Provider business mailing address

15045 MYSTIC LAKE DR NW
PRIOR LAKE MN
55372-9011
US

V. Phone/Fax

Practice location:
  • Phone: 952-233-2900
  • Fax: 952-233-8066
Mailing address:
  • Phone: 952-233-2900
  • Fax: 952-233-8066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number262982
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM WEIERS
Title or Position: PHARMACY DIRECTOR
Credential: RPH
Phone: 952-233-2900