Provider Demographics
NPI:1932651122
Name:AVERA ST. MARY'S
Entity Type:Organization
Organization Name:AVERA ST. MARY'S
Other - Org Name:AVERA ST. MARY'S CAMPUS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-224-3144
Mailing Address - Street 1:100 MAC LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-3391
Mailing Address - Country:US
Mailing Address - Phone:605-224-7334
Mailing Address - Fax:605-945-4292
Practice Address - Street 1:100 MAC LN
Practice Address - Street 2:SUITE 101
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3391
Practice Address - Country:US
Practice Address - Phone:605-224-7334
Practice Address - Fax:605-945-4292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336S0011X
SD100-20443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165791OtherPK