Provider Demographics
NPI:1437203882
Name:SHAKOPEE MDEWAKANTON SIOUX COMM PHCY
Entity Type:Organization
Organization Name:SHAKOPEE MDEWAKANTON SIOUX COMM PHCY
Other - Org Name:SMSC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:952-233-2900
Mailing Address - Street 1:15045 MYSTIC LAKE DR NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-9011
Mailing Address - Country:US
Mailing Address - Phone:952-233-2900
Mailing Address - Fax:952-233-8066
Practice Address - Street 1:15045 MYSTIC LAKE DR NW
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-9011
Practice Address - Country:US
Practice Address - Phone:952-233-2900
Practice Address - Fax:952-233-8066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262982333600000X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049180OtherPK