Healthcare Provider Details

I. General information

NPI: 1043313950
Provider Name (Legal Business Name): LAVONNE ISAAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 BROADWAY
CENTERVILLE SD
57014-0070
US

IV. Provider business mailing address

141 DAKOTA STREET
CENTERVILLE SD
57014
US

V. Phone/Fax

Practice location:
  • Phone: 605-563-2243
  • Fax: 605-563-3784
Mailing address:
  • Phone: 605-563-2116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT-0301
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: