Provider Demographics
NPI:1235371535
Name:MEDVANTX INC
Entity Type:Organization
Organization Name:MEDVANTX INC
Other - Org Name:MEDVANTX INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:605-978-3963
Mailing Address - Street 1:2503 E 54TH ST N
Mailing Address - Street 2:STE M
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-5563
Mailing Address - Country:US
Mailing Address - Phone:605-978-3980
Mailing Address - Fax:888-825-8473
Practice Address - Street 1:2503 E 54TH ST N
Practice Address - Street 2:STE M
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-5563
Practice Address - Country:US
Practice Address - Phone:605-978-3980
Practice Address - Fax:888-825-8473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SD10019503336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119886OtherPK