Provider Demographics
NPI:1699878710
Name:PRESCRIPTION SHOP INC
Entity type:Organization
Organization Name:PRESCRIPTION SHOP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,AO
Authorized Official - Prefix:
Authorized Official - First Name:CLIFF
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN HOVE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-336-1816
Mailing Address - Street 1:1200 S 7TH ST AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105
Mailing Address - Country:US
Mailing Address - Phone:605-336-1816
Mailing Address - Fax:605-336-1677
Practice Address - Street 1:1200 S 7TH ST AVE
Practice Address - Street 2:STE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-336-1816
Practice Address - Fax:605-336-1677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SD100-09903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8500180Medicaid
2093550OtherPK