Provider Demographics
NPI:1306601794
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:CBO PROV ENRLMT
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 PLANT ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-0304
Practice Address - Country:US
Practice Address - Phone:605-322-1450
Practice Address - Fax:605-322-1451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy