Provider Demographics
NPI:1174845101
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:UI HEALTHCARE-RIVER CROSSING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT FOR MEDICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-335-8064
Mailing Address - Street 1:3056 RIVER CROSSING COURT
Mailing Address - Street 2:STE A
Mailing Address - City:RIVERSIDE
Mailing Address - State:IA
Mailing Address - Zip Code:52327-4724
Mailing Address - Country:US
Mailing Address - Phone:319-467-8383
Mailing Address - Fax:319-467-8378
Practice Address - Street 1:3056 RIVER CROSSING COURT
Practice Address - Street 2:STE A
Practice Address - City:RIVERSIDE
Practice Address - State:IA
Practice Address - Zip Code:52327
Practice Address - Country:US
Practice Address - Phone:319-467-8383
Practice Address - Fax:319-467-8378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18469333600000X
3336C0002X
IA13703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0402616Medicaid
1623772OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IB1813Medicare PIN
IA0402616Medicaid