Basic Information
| Provider Information | |||||||||
| NPI: | 1285662742 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRAIRIE LAKES HEALTHCARE SYSTEM INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CAMPUS PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 9TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572011548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058827000 | ||||||||
| FaxNumber: | 6058827607 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 9TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572011548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058827000 | ||||||||
| FaxNumber: | 6058827607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 01/03/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6058827718 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 100-1855 | SD | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 9162610 | 05 | SD | MEDICAID |