Healthcare Provider Details

I. General information

NPI: 1407995020
Provider Name (Legal Business Name): MARY JO THOENNES RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY JO DYLLA RPH

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

IV. Provider business mailing address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

V. Phone/Fax

Practice location:
  • Phone: 605-742-3600
  • Fax:
Mailing address:
  • Phone: 605-742-3795
  • Fax: 605-698-3128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number115838
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4863
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: