Provider Demographics
NPI:1063687580
Name:MCLD CORPORATION
Entity Type:Organization
Organization Name:MCLD CORPORATION
Other - Org Name:SUMNER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TUETKEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:319-221-1050
Mailing Address - Street 1:207 2ND AVE SE
Mailing Address - Street 2:STE A
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-1238
Mailing Address - Country:US
Mailing Address - Phone:319-221-1033
Mailing Address - Fax:319-221-1050
Practice Address - Street 1:100 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:IA
Practice Address - Zip Code:50674-1430
Practice Address - Country:US
Practice Address - Phone:563-578-5068
Practice Address - Fax:563-578-5190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IA433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1063687580Medicaid
1623467OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IA1063687580Medicaid