Provider Demographics
NPI:1902930613
Name:STATE OF SOUTH DAKOTA-DIVISION OF
Entity Type:Organization
Organization Name:STATE OF SOUTH DAKOTA-DIVISION OF
Other - Org Name:SOUTH DAKOTA STATE VETERANS HOME PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-745-5127
Mailing Address - Street 1:2500 MINNEKAHTA AVE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-1129
Mailing Address - Country:US
Mailing Address - Phone:605-745-5127
Mailing Address - Fax:605-745-7329
Practice Address - Street 1:2500 MINNEKAHTA AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-1129
Practice Address - Country:US
Practice Address - Phone:605-745-5127
Practice Address - Fax:605-745-4617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336I0012X, 333600000X
SD100-16273336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2094310OtherPK
4353455OtherOTHER ID NUMBER