Provider Demographics
NPI:1922058890
Name:BROTHERS PHARMACIES, INC.
Entity Type:Organization
Organization Name:BROTHERS PHARMACIES, INC.
Other - Org Name:NORTHSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARAMBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-352-9222
Mailing Address - Street 1:100 DAKOTA AVE N. SUITE A
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350
Mailing Address - Country:US
Mailing Address - Phone:605-352-9222
Mailing Address - Fax:
Practice Address - Street 1:100 DAKOTA AVE N STE A
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-1630
Practice Address - Country:US
Practice Address - Phone:605-352-9222
Practice Address - Fax:605-352-4861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
SD100-1874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8510040Medicaid
SD8510040Medicaid