Provider Demographics
NPI:1477660512
Name:DYKSTRA PHARMACY CO
Entity Type:Organization
Organization Name:DYKSTRA PHARMACY CO
Other - Org Name:HULL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:DYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:712-439-1611
Mailing Address - Street 1:1044 MAIN ST
Mailing Address - Street 2:BOX 309
Mailing Address - City:HULL
Mailing Address - State:IA
Mailing Address - Zip Code:51238
Mailing Address - Country:US
Mailing Address - Phone:712-439-1611
Mailing Address - Fax:712-439-1612
Practice Address - Street 1:1044 MAIN STREET
Practice Address - Street 2:BOX 309
Practice Address - City:HULL
Practice Address - State:IA
Practice Address - Zip Code:51239
Practice Address - Country:US
Practice Address - Phone:712-439-1611
Practice Address - Fax:712-439-1612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14742183500000X, 315P00000X, 332BP3500X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Not Answered315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0081661Medicaid
IA1606346Medicare UPIN
IA0153040001Medicare ID - Type Unspecified