Healthcare Provider Details

I. General information

NPI: 1386738102
Provider Name (Legal Business Name): AVERA ST LUKES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 S STATE ST
ABERDEEN SD
57401-4527
US

IV. Provider business mailing address

305 S STATE ST
ABERDEEN SD
57401-4527
US

V. Phone/Fax

Practice location:
  • Phone: 605-622-5545
  • Fax: 605-622-5019
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number1000486
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RON JACOBSON
Title or Position: PRES
Credential:
Phone: 605-627-5625