Provider Demographics
NPI:1346266202
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JOSPEH
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:500 E 56TH ST N STE 3150
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-0408
Mailing Address - Country:US
Mailing Address - Phone:605-322-8300
Mailing Address - Fax:605-322-8361
Practice Address - Street 1:500 E 56TH ST N STE 3150
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-0408
Practice Address - Country:US
Practice Address - Phone:605-322-8300
Practice Address - Fax:605-322-8361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MN261725333600000X
IA32543336C0003X
TX307473336S0011X
AZY0067813336S0011X
SD100-18673336S0011X
NE6373336S0011X, 3336C0003X
NDPHAR3963336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8504220Medicaid
IA1346266202Medicaid
MN1346266202Medicaid
NE100261606-00Medicaid
2094315OtherPK