Healthcare Provider Details

I. General information

NPI: 1902930613
Provider Name (Legal Business Name): STATE OF SOUTH DAKOTA-DIVISION OF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MINNEKAHTA AVE
HOT SPRINGS SD
57747-1129
US

IV. Provider business mailing address

2500 MINNEKAHTA AVE
HOT SPRINGS SD
57747-1129
US

V. Phone/Fax

Practice location:
  • Phone: 605-745-5127
  • Fax: 605-745-4617
Mailing address:
  • Phone: 605-745-5127
  • Fax: 605-745-7329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number100-1627
License Number StateSD

VIII. Authorized Official

Name: JOHN LANE
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 605-745-5127