Provider Demographics
NPI:1184634347
Name:PHARMERICA MIDWEST LLC
Entity Type:Organization
Organization Name:PHARMERICA MIDWEST LLC
Other - Org Name:PHARMERICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CANERIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-627-7100
Mailing Address - Street 1:PO BOX 409244
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-9244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4105 WESTCOR COURT
Practice Address - Street 2:SUITE 1
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241
Practice Address - Country:US
Practice Address - Phone:319-545-7090
Practice Address - Fax:319-545-7095
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHARMERICA CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-09
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BP3500X
IA12063336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0498048Medicaid
IA0498048Medicaid
5312700002Medicare NSC