Provider Demographics
NPI:1114095403
Name:INDIAN HILLS PHARMACY
Entity Type:Organization
Organization Name:INDIAN HILLS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SIMMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:712-255-9150
Mailing Address - Street 1:1551 INDIAN HILLS DR
Mailing Address - Street 2:STE 101
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-1859
Mailing Address - Country:US
Mailing Address - Phone:712-255-9150
Mailing Address - Fax:712-255-2946
Practice Address - Street 1:1551 INDIAN HILLS DR
Practice Address - Street 2:STE 101
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-1859
Practice Address - Country:US
Practice Address - Phone:712-255-9150
Practice Address - Fax:712-255-2946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-03
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0142646Medicaid
IA0142646Medicaid