Provider Demographics
NPI:1013182047
Name:IOLA PHARMACY INC
Entity Type:Organization
Organization Name:IOLA PHARMACY INC
Other - Org Name:IOLA PHARMACY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-365-9332
Mailing Address - Street 1:109 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-3330
Mailing Address - Country:US
Mailing Address - Phone:620-365-3176
Mailing Address - Fax:620-365-5111
Practice Address - Street 1:1408 EAST ST
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-4402
Practice Address - Country:US
Practice Address - Phone:620-365-6848
Practice Address - Fax:620-365-6849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
KS2101783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2027874OtherPK
KS100080440HMedicaid