Basic Information
| Provider Information | |||||||||
| NPI: | 1326593500 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONUMENT HEALTH HOME PLUS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MONUMENT HEALTH HOME PLUS PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860013 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554860013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057557649 | ||||||||
| FaxNumber: | 6057557884 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 N 10TH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057178741 | ||||||||
| FaxNumber: | 6057178734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2016 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TILLES | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT MONUMENT HEALTH HOME PLUS | ||||||||
| AuthorizedOfficialTelephone: | 6055191179 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MONUMENT HEALTH HOME PLUS, LLC | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.