Provider Demographics
NPI:1003352949
Name:CENTRAL IOWA HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:CENTRAL IOWA HOSPITAL CORPORATION
Other - Org Name:IMMC OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-241-5942
Mailing Address - Street 1:1200 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1406
Mailing Address - Country:US
Mailing Address - Phone:515-241-5942
Mailing Address - Fax:
Practice Address - Street 1:1200 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1406
Practice Address - Country:US
Practice Address - Phone:515-241-5936
Practice Address - Fax:515-241-5925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1591333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166700OtherPK