Healthcare Provider Details

I. General information

NPI: 1124177100
Provider Name (Legal Business Name): SDSU JACKRABBIT PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N CAMPUS DR SDSU WELLNESS CENTER ROOM 119
BROOKINGS SD
57007-0001
US

IV. Provider business mailing address

1440 NORTH CAMPUS DR RM 102
BROOKINGS SD
57007
US

V. Phone/Fax

Practice location:
  • Phone: 605-688-5410
  • Fax: 605-688-5267
Mailing address:
  • Phone: 605-688-5410
  • Fax: 605-688-5267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number100-0492
License Number StateSD

VIII. Authorized Official

Name: MICHAELA WILLIS
Title or Position: VP FOR STUDENT AFFAIRS
Credential:
Phone: 605-688-4493