Healthcare Provider Details

I. General information

NPI: 1346825387
Provider Name (Legal Business Name): MARY JOHANNA HAUPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
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:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT-0988
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: