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General NPI Number Information
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NPI Number | 1669871000
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Entity Type | Organization
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Legal Business Name | AVERA MCKENNAN
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Dates
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Enumeration Date | 08/21/2014
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Last Update Date | 04/29/2025
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Provider Practice Location Address
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Address Line | 4101 W MEMORY CIRCLE STE 120
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City | SIOUX FALLS
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State | SD
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Zip | 57107-6504
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Country | US
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Telephone | 855-322-6922
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Fax | 855-971-3544
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Provider Business Mailing Address
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Address Line | 3820 N POTSDAM AVE STE 2
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City | SIOUX FALLS
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State | SD
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Zip | 57104-7057
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Country | US
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Telephone | 605-322-1450
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Fax | 605-322-1451
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | RONALD JOSEPH PLACE
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Credential | MD
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Telephone | 605-322-7903
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 100-1994
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License Number State | SD
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