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General NPI Number Information
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NPI Number | 1962787440
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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 | 10/17/2011
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Last Update Date | 07/19/2018
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Provider Practice Location Address
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Address Line | 4400 W 69TH ST STE 300
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City | SIOUX FALLS
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State | SD
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Zip | 57108-8170
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Country | US
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Telephone | 605-322-5948
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Fax | 605-322-5949
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Provider Business Mailing Address
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Address Line | 4400 W 69TH ST STE 300
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City | SIOUX FALLS
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State | SD
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Zip | 57108-8170
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Country | US
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Telephone | 605-322-5948
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Fax | 605-322-5949
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Authorized Official
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Title or Position | RETAIL PHARMACY MANAGER
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Name | DARREL MUTCHLER
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Credential | PHARMD
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Telephone | 605-322-8331
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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 | 100-1967
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License Number State | SD
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 1020
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License Number State | NE
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 054.019698
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 264333
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License Number State | MN
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Taxonomy #5
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 4574
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License Number State | IA
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