Provider Demographics
NPI:1134117005
Name:MCLD CORPORATION
Entity Type:Organization
Organization Name:MCLD CORPORATION
Other - Org Name:LONG DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TUETKEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:319-221-1050
Mailing Address - Street 1:209 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-1405
Mailing Address - Country:US
Mailing Address - Phone:319-221-1050
Mailing Address - Fax:319-221-1033
Practice Address - Street 1:419 E 1ST ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IA
Practice Address - Zip Code:52310-1506
Practice Address - Country:US
Practice Address - Phone:319-465-4906
Practice Address - Fax:319-465-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IA1313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0026955Medicaid
2025941OtherPK
0543810001Medicare NSC