Provider Demographics
NPI:1104502137
Name:CAMPBELL, CARLY R
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:R
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N POPLAR AVE
Mailing Address - Street 2:PO BOX 735
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064
Mailing Address - Country:US
Mailing Address - Phone:605-553-8785
Mailing Address - Fax:
Practice Address - Street 1:2701 S MINNESOTA AVE STE 1
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4746
Practice Address - Country:US
Practice Address - Phone:605-367-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist