Provider Demographics
NPI:1407230220
Name:MUTSCHELKNAUS, ASHLEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:MUTSCHELKNAUS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47713 209TH ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:SD
Mailing Address - Zip Code:57002-6511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:910 22ND AVE S
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2830
Practice Address - Country:US
Practice Address - Phone:605-692-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8502790Medicaid
4353126OtherNCPDP