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General NPI Number Information
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NPI Number | 1710359252
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Entity Type | Organization
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Legal Business Name | AVERA QUEEN OF PEACE
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Dates
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Enumeration Date | 10/23/2015
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Last Update Date | 09/14/2020
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Provider Practice Location Address
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Address Line | 1900 GRASSLAND DR STE 101
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City | MITCHELL
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State | SD
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Zip | 57301
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Country | US
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Telephone | 605-995-5670
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Fax | 605-996-6805
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Provider Business Mailing Address
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Address Line | 1900 GRASSLAND DR STE 101
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City | MITCHELL
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State | SD
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Zip | 57301
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Country | US
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Telephone | 605-995-5670
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Fax | 605-996-6805
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DOUGLAS EKEREN
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Credential |
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Telephone | 605-668-8321
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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 | 100-2030
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License Number State | SD
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