Provider Demographics
NPI:1083782569
Name:CAMANCHE PHARMACY INC
Entity Type:Organization
Organization Name:CAMANCHE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:RICHESON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:563-259-8361
Mailing Address - Street 1:818 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMANCHE
Mailing Address - State:IA
Mailing Address - Zip Code:52730
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
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:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA140333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0011692Medicaid
1604873OtherNCPDP