Provider Demographics
NPI:1407959539
Name:FAMILY PHARMACY OF MOBRIDGE INC
Entity Type:Organization
Organization Name:FAMILY PHARMACY OF MOBRIDGE INC
Other - Org Name:FAMILY PHARMACY-CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-845-8140
Mailing Address - Street 1:1317 10TH AVE W
Mailing Address - Street 2:BOX 759
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-1146
Mailing Address - Country:US
Mailing Address - Phone:605-845-8140
Mailing Address - Fax:605-845-8146
Practice Address - Street 1:1317 10TH AVE W
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-1146
Practice Address - Country:US
Practice Address - Phone:605-845-8140
Practice Address - Fax:605-845-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0002X, 3336L0003X
SD10017973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093771OtherPK
SD8501062Medicaid
ND020988Medicaid