Provider Demographics
NPI:1124177100
Name:SDSU JACKRABBIT PHARMACY
Entity type:Organization
Organization Name:SDSU JACKRABBIT PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FOR STUDENT AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:MICHAELA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-688-4493
Mailing Address - Street 1:1440 NORTH CAMPUS DR RM 102
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57007
Mailing Address - Country:US
Mailing Address - Phone:605-688-5410
Mailing Address - Fax:605-688-5267
Practice Address - Street 1:N CAMPUS DR
Practice Address - Street 2:SDSU WELLNESS CENTER ROOM 119
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57007-0001
Practice Address - Country:US
Practice Address - Phone:605-688-5410
Practice Address - Fax:605-688-5267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SD100-04923336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093681OtherPK