Provider Demographics
NPI:1184841876
Name:MOAD, JOAN MACKENZIE (RPH)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MACKENZIE
Last Name:MOAD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 SOUTH MAIN ST
Mailing Address - Street 2:PO BOX 515
Mailing Address - City:ALLISON
Mailing Address - State:IA
Mailing Address - Zip Code:50602-0515
Mailing Address - Country:US
Mailing Address - Phone:319-267-2626
Mailing Address - Fax:
Practice Address - Street 1:416 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ALLISON
Practice Address - State:IA
Practice Address - Zip Code:50602-0515
Practice Address - Country:US
Practice Address - Phone:319-267-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist