Provider Demographics
NPI:1154464212
Name:DAKOTA COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:DAKOTA COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOKKEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-692-7992
Mailing Address - Street 1:628 MAIN AVE
Mailing Address - Street 2:STE C
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-1423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:628 MAIN AVE
Practice Address - Street 2:STE C
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-1423
Practice Address - Country:US
Practice Address - Phone:605-692-7992
Practice Address - Fax:605-692-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10019223336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4353998OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4353998OtherOTHER ID NUMBER