Healthcare Provider Details

I. General information

NPI: 1073237376
Provider Name (Legal Business Name): KRISTIN DVORAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S BURR ST
MITCHELL SD
57301-4731
US

IV. Provider business mailing address

901 S BURR ST
MITCHELL SD
57301-4731
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-3179
  • Fax:
Mailing address:
  • Phone: 605-996-3179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5578
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: