1114002284 NPI number — PROFESSIONAL COMPOUNDING CENTER OF IOWA, INC.

Table of content: (NPI 1114002284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114002284 NPI number — PROFESSIONAL COMPOUNDING CENTER OF IOWA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL COMPOUNDING CENTER OF IOWA, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1114002284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2104 KIMBALL AVE.
Provider Second Line Business Mailing Address:
SUITE A.
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50702-5037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-433-0393
Provider Business Mailing Address Fax Number:
319-234-5627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2104 KIMBALL AVE.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50702-5037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-433-0393
Provider Business Practice Location Address Fax Number:
319-234-5627
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUGHES
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
PHARMACIST-IN-CHARGE/MANAGER
Authorized Official Telephone Number:
319-433-0393

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0489625 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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