Provider Demographics
NPI:1376694224
Name:DAWN R. EKLUM
Entity Type:Organization
Organization Name:DAWN R. EKLUM
Other - Org Name:SOUTH DAYTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER SUPERVISING RPH
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:EKLUM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:716-988-3410
Mailing Address - Street 1:P.O. BOX 290
Mailing Address - Street 2:303 PINE ST
Mailing Address - City:SOUTH DAYTON
Mailing Address - State:NY
Mailing Address - Zip Code:14138-0290
Mailing Address - Country:US
Mailing Address - Phone:716-988-3410
Mailing Address - Fax:716-988-3720
Practice Address - Street 1:303 PINE ST
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTON
Practice Address - State:NY
Practice Address - Zip Code:14138-0290
Practice Address - Country:US
Practice Address - Phone:716-988-3410
Practice Address - Fax:716-988-3720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02901600Medicaid
NY5918970001Medicare NSC