MEDICARE: KEATON MARK MOFFITT PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	6586	SD

General Provider Information

NPI Number	:	1144715830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEATON MARK MOFFITT PHARMD

Provider Business Mailing Address
First Line	:	2701 S MINNESOTA AVE STE 1
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-4787
Country	:	US
Telephone Number	:	605-367-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	708 S RIVERWARD DR
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-4604
Country	:	US
Telephone Number	:	605-261-2512
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2018
Last Update Date	:	06/26/2018

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