Provider Demographics
NPI:1124039631
Name:NUDAK VENTURES LLC
Entity Type:Organization
Organization Name:NUDAK VENTURES LLC
Other - Org Name:NUCARA PHARMACY #27
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF RECEIVABLES
Authorized Official - Prefix:
Authorized Official - First Name:LORI ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-366-3440
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:IA
Mailing Address - Zip Code:50621-0640
Mailing Address - Country:US
Mailing Address - Phone:641-366-3440
Mailing Address - Fax:641-366-3442
Practice Address - Street 1:4927 MAPLE DR
Practice Address - Street 2:STE. 100
Practice Address - City:PLEASANT HILL
Practice Address - State:IA
Practice Address - Zip Code:50327-2030
Practice Address - Country:US
Practice Address - Phone:515-264-1503
Practice Address - Fax:515-265-6124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
IA14363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137747OtherPK
IA0403978Medicaid