Healthcare Provider Details

I. General information

NPI: 1750442901
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 S CLIFF AVE SUITE CP
SIOUX FALLS SD
57105-1008
US

IV. Provider business mailing address

1325 S CLIFF AVE SUITE CP
SIOUX FALLS SD
57105-1008
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-8326
  • Fax: 605-322-8330
Mailing address:
  • Phone: 605-322-8326
  • Fax: 605-322-8330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1000452
License Number StateSD

VIII. Authorized Official

Name: RONALD JOSEPH PLACE
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 605-322-7903