Provider Demographics
NPI:1265447874
Name:PEMBERS DRUG INC
Entity Type:Organization
Organization Name:PEMBERS DRUG INC
Other - Org Name:PEMBERS DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PEMBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-476-5379
Mailing Address - Street 1:1415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCK VALLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51247-1223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCK VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51247-1223
Practice Address - Country:US
Practice Address - Phone:712-476-5379
Practice Address - Fax:712-476-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA545333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1607158OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IA0081653Medicaid
IA0532450001Medicare NSC