1245393263 NPI number — NUDAK VENTURES LLC

Table of content: (NPI 1245393263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245393263 NPI number — NUDAK VENTURES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NUDAK VENTURES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NUCARA PHARMACY #40
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245393263
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 640
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONRAD
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50621-0640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-366-3440
Provider Business Mailing Address Fax Number:
641-366-3442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 W CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONONA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52159-8224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-539-2348
Provider Business Practice Location Address Fax Number:
563-539-4385
Provider Enumeration Date:
12/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
ACQUISITIONS MANAGER
Authorized Official Telephone Number:
641-366-3440

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 302 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 714446 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".