Provider Demographics
NPI:1114002284
Name:PROFESSIONAL COMPOUNDING CENTER OF IOWA, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL COMPOUNDING CENTER OF IOWA, INC.
Other - Org Name:GREENWOOD COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:319-433-0393
Mailing Address - Street 1:2104 KIMBALL AVE.
Mailing Address - Street 2:SUITE A.
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5037
Mailing Address - Country:US
Mailing Address - Phone:319-433-0393
Mailing Address - Fax:319-234-5627
Practice Address - Street 1:2104 KIMBALL AVE.
Practice Address - Street 2:SUITE A
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5037
Practice Address - Country:US
Practice Address - Phone:319-433-0393
Practice Address - Fax:319-234-5627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0489625Medicaid