Provider Demographics
NPI:1326027988
Name:WAVERLY HEALTH CENTER
Entity Type:Organization
Organization Name:WAVERLY HEALTH CENTER
Other - Org Name:CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-352-4120
Mailing Address - Street 1:312 9TH ST SW
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-2916
Mailing Address - Country:US
Mailing Address - Phone:319-483-4100
Mailing Address - Fax:319-483-4101
Practice Address - Street 1:312 9TH ST SW
Practice Address - Street 2:SUITE 1000
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2916
Practice Address - Country:US
Practice Address - Phone:319-483-4100
Practice Address - Fax:319-483-4101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAVERLY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-12
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IA12603336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0450494Medicaid
IA1260OtherPHARMACY LICENSE #
IA1622213OtherNCPDP
IAI14523Medicare PIN
IA0974150002Medicare NSC