Provider Demographics
NPI:1154460996
Name:CUSTER COMMUNITY PHARMACY LLC
Entity Type:Organization
Organization Name:CUSTER COMMUNITY PHARMACY LLC
Other - Org Name:CARSON DRUG
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DILLON
Authorized Official - Middle Name:
Authorized Official - Last Name:KJERSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-270-7609
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:PHILIP
Mailing Address - State:SD
Mailing Address - Zip Code:57567-0878
Mailing Address - Country:US
Mailing Address - Phone:605-270-7609
Mailing Address - Fax:605-859-3026
Practice Address - Street 1:521 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-1531
Practice Address - Country:US
Practice Address - Phone:605-673-2225
Practice Address - Fax:605-673-3577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SD10020513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175295OtherPK
SD1154460996Medicaid