Provider Demographics
NPI:1275602518
Name:SERGEANT BLUFF PHARMACY INC
Entity Type:Organization
Organization Name:SERGEANT BLUFF PHARMACY INC
Other - Org Name:SERGEANT BLUFF PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-943-1494
Mailing Address - Street 1:105 GAUL DR STE A
Mailing Address - Street 2:
Mailing Address - City:SERGEANT BLUFF
Mailing Address - State:IA
Mailing Address - Zip Code:51054-8963
Mailing Address - Country:US
Mailing Address - Phone:712-943-1494
Mailing Address - Fax:712-943-1496
Practice Address - Street 1:105 GAUL DR STE A
Practice Address - Street 2:
Practice Address - City:SERGEANT BLUFF
Practice Address - State:IA
Practice Address - Zip Code:51054-8963
Practice Address - Country:US
Practice Address - Phone:712-943-1494
Practice Address - Fax:712-943-1496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IA13043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0736173Medicaid
2030418OtherPK
NE10025475600Medicaid