Provider Demographics
NPI:1083703037
Name:ABERDEEN MEDICAL CENTER PHARMACY, INC
Entity Type:Organization
Organization Name:ABERDEEN MEDICAL CENTER PHARMACY, INC
Other - Org Name:STATE STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:TAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-225-1945
Mailing Address - Street 1:105 S STATE ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4500
Mailing Address - Country:US
Mailing Address - Phone:605-225-1945
Mailing Address - Fax:605-725-0037
Practice Address - Street 1:105 S STATE ST
Practice Address - Street 2:SUITE 111
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4500
Practice Address - Country:US
Practice Address - Phone:605-225-1945
Practice Address - Fax:605-725-0037
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABERDEEN MEDICAL CENTER PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-11
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10016163336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8500310Medicaid
SD4304553OtherNABP#
SD8500310Medicaid