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Avera Queen of Peace

Organization Active NPI Community/Retail Pharmacy · Mitchell, SD

NPI 1710359252 · NPPES record last updated Sep 14, 2020

Key facts

NPI
1710359252
Entity type
Organization (NPI type 2)
Primary specialty
Community/Retail Pharmacy 3336C0003X
License
100-2030 (SD)
Legal business name
AVERA QUEEN OF PEACE
Practice address
1900 Grassland Dr
Ste 101
Mitchell, SD 57301
Phone
(605) 995-5670
Fax
(605) 996-6805
NPI assigned
Oct 23, 2015
Organization subpart
No

Authorized official

Name
Douglas Ekeren
Title
President/Ceo
Phone
(605) 668-8321

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs with the same Medicare PAC ID 11

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Corporate family (same tax ID) 28

Organizations that report the same tax identification number in the National Provider Directory.

View all 28

Practitioners 123

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 123

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Avera Grassland Pharmacy
1900 Grassland Dr, Mitchell, SD 57301-6386 · (605) 995-5670		 Epoetin|Immunosuppressive Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Orthoses: Off-The-Shelf Accepts assignment
Participating since Jun 1, 2000

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in SD

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Avera Weskota Memorial Medical Center
Wessington Springs, SD · CCN 43Z324		 Hospital Operational/Managerial Control Jun 1, 2000

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20220718003137 SD DME Supplier - Pharmacy 9335050806 Practice locations: Mitchell, SD
O20240229000380 SD Part B Supplier - Mass Immunization (Roster Biller Only) 9335050806 Practice locations: Mitchell, SD

National Provider Directory

Tax ID family
ER Phy (29 organizations share this tax ID)

Locations

1900 Grassland Dr
Ste 101
Mitchell, SD 57301
Phone (605) 995-5670

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 100-2030 SD Yes

Addresses

Primary practice location

1900 Grassland Dr
Ste 101
Mitchell, SD 57301

Mailing address

1900 Grassland Dr
Ste 101
Mitchell, SD 57301
Phone (605) 995-5670

Other identifiers

IdentifierTypeStateIssuer
2154706OtherPK

Other names

  • Avera Grassland Pharmacy Doing business as

Other providers in Mitchell, SD

All providers in Mitchell, SD · Community/Retail Pharmacy in South Dakota

Sources for this page

Verify at the official NPI Registry.