Provider Demographics
NPI:1164064093
Name:CJK PHARMACY, LLC
Entity Type:Organization
Organization Name:CJK PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANSCHEPEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-200-1188
Mailing Address - Street 1:3100 E AVE NW STE 102
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-2962
Mailing Address - Country:US
Mailing Address - Phone:319-200-1188
Mailing Address - Fax:319-200-1003
Practice Address - Street 1:3100 E AVE NW STE 102
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52405-2962
Practice Address - Country:US
Practice Address - Phone:319-200-1188
Practice Address - Fax:319-200-1003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CJK PHARMACY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0713135Medicaid