Provider Demographics
NPI:1073810495
Name:CAMANCHE DRUG STORE
Entity Type:Organization
Organization Name:CAMANCHE DRUG STORE
Other - Org Name:CAMANCHE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-321-6324
Mailing Address - Street 1:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:CAMANCHE
Mailing Address - State:IA
Mailing Address - Zip Code:52730-0225
Mailing Address - Country:US
Mailing Address - Phone:563-259-8361
Mailing Address - Fax:563-259-9208
Practice Address - Street 1:818 7TH AVE
Practice Address - Street 2:
Practice Address - City:CAMANCHE
Practice Address - State:IA
Practice Address - Zip Code:52730-1811
Practice Address - Country:US
Practice Address - Phone:563-259-8361
Practice Address - Fax:563-259-9208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1624027OtherNCPDP PROVIDER IDENTIFICATION NUMBER