Provider Demographics
NPI:1467715821
Name:PHARMACY ON 8TH LLC
Entity Type:Organization
Organization Name:PHARMACY ON 8TH LLC
Other - Org Name:PHARMACY ON 8TH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESUS-ROETLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-330-3154
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:WELLMAN
Mailing Address - State:IA
Mailing Address - Zip Code:52356-0010
Mailing Address - Country:US
Mailing Address - Phone:319-646-3388
Mailing Address - Fax:319-646-3389
Practice Address - Street 1:221 8TH AVE
Practice Address - Street 2:
Practice Address - City:WELLMAN
Practice Address - State:IA
Practice Address - Zip Code:52356-4707
Practice Address - Country:US
Practice Address - Phone:319-646-3388
Practice Address - Fax:319-646-3389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0108660Medicaid
2135428OtherPK