Provider Demographics
NPI:1144715830
Name:MOFFITT, KEATON MARK (PHARMD)
Entity type:Individual
Prefix:
First Name:KEATON
Middle Name:MARK
Last Name:MOFFITT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 S MINNESOTA AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4787
Mailing Address - Country:US
Mailing Address - Phone:605-367-2800
Mailing Address - Fax:
Practice Address - Street 1:708 S RIVERWARD DR
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-4604
Practice Address - Country:US
Practice Address - Phone:605-261-2512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist