Provider Demographics
NPI:1467569038
Name:MEDICAP PHARMACY
Entity Type:Organization
Organization Name:MEDICAP PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKONE BURKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:563-382-8765
Mailing Address - Street 1:702 MONTGOMERY ST
Mailing Address - Street 2:STE B
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 MONTGOMERY ST
Practice Address - Street 2:STE B
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2317
Practice Address - Country:US
Practice Address - Phone:563-382-8765
Practice Address - Fax:563-382-1329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12953336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1245110001Medicaid
1622718OtherOTHER ID NUMBER
1622718OtherOTHER ID NUMBER-COMMERCIAL NUMBER