1639625155 NPI number — MERCY HEALTH SERVICES-IOWA CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639625155 NPI number — MERCY HEALTH SERVICES-IOWA CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY HEALTH SERVICES-IOWA CORP
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:
MERCYONE CLEAR LAKE PHARMACY
Provider Other Organization Name Type Code:
5
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:
1639625155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1410 6TH AVE S STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEAR LAKE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50428-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-231-8900
Provider Business Mailing Address Fax Number:
641-231-8910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 6TH AVE S STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEAR LAKE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50428-2606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-231-8900
Provider Business Practice Location Address Fax Number:
641-231-8910
Provider Enumeration Date:
08/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TRAMMEL
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT TREASURER
Authorized Official Telephone Number:
641-428-7984

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  1579 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2163823 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0409056 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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