1184634347 NPI number — PHARMERICA MIDWEST LLC

Table of content: (NPI 1184634347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184634347 NPI number — PHARMERICA MIDWEST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMERICA MIDWEST 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:
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:
1184634347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 409244
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-9244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4105 WESTCOR COURT
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CORALVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-545-7090
Provider Business Practice Location Address Fax Number:
319-545-7095
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANERIS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
502-627-7100

Provider Taxonomy Codes

  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 1206 , 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: 0498048 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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