Provider Demographics
NPI:1750442901
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MCKENNAN CAMPUS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:1325 S CLIFF AVE
Mailing Address - Street 2:SUITE CP
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1008
Mailing Address - Country:US
Mailing Address - Phone:605-322-8326
Mailing Address - Fax:605-322-8330
Practice Address - Street 1:1325 S CLIFF AVE
Practice Address - Street 2:SUITE CP
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1008
Practice Address - Country:US
Practice Address - Phone:605-322-8326
Practice Address - Fax:605-322-8330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SD10004523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4304010OtherOTHER ID NUMBER
IA1750442901Medicaid
SD8503150Medicaid
MN1750442901Medicaid
IA1750442901Medicaid