Healthcare Provider Details

I. General information

NPI: 1710359252
Provider Name (Legal Business Name): AVERA QUEEN OF PEACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 GRASSLAND DR STE 101
MITCHELL SD
57301
US

IV. Provider business mailing address

1900 GRASSLAND DR STE 101
MITCHELL SD
57301
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-5670
  • Fax: 605-996-6805
Mailing address:
  • Phone: 605-995-5670
  • Fax: 605-996-6805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number100-2030
License Number StateSD

VIII. Authorized Official

Name: DOUGLAS EKEREN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 605-668-8321