Provider Demographics
NPI:1023173796
Name:STATELINE DRUG INC
Entity type:Organization
Organization Name:STATELINE DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SONSALLA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:605-374-3897
Mailing Address - Street 1:301 MAIN AVE
Mailing Address - Street 2:BOX 360
Mailing Address - City:LEMMON
Mailing Address - State:SD
Mailing Address - Zip Code:57638-1419
Mailing Address - Country:US
Mailing Address - Phone:605-374-3897
Mailing Address - Fax:605-374-5510
Practice Address - Street 1:301 MAIN AVE
Practice Address - Street 2:BOX 360
Practice Address - City:LEMMON
Practice Address - State:SD
Practice Address - Zip Code:57638-1419
Practice Address - Country:US
Practice Address - Phone:605-374-3897
Practice Address - Fax:605-374-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-23
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 3336C0003X
SD100-0056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8501362Medicaid
ND020209Medicaid
ND020209Medicaid