Provider Demographics
NPI:1497766901
Name:NUDAK VENTURES LLC
Entity Type:Organization
Organization Name:NUDAK VENTURES LLC
Other - Org Name:NUCARA PHARMACY #12
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACQUISITIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-366-3440
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:IA
Mailing Address - Zip Code:50621-0640
Mailing Address - Country:US
Mailing Address - Phone:641-366-3440
Mailing Address - Fax:641-366-3442
Practice Address - Street 1:500 2ND ST
Practice Address - Street 2:
Practice Address - City:TRAER
Practice Address - State:IA
Practice Address - Zip Code:50675-1139
Practice Address - Country:US
Practice Address - Phone:319-478-8711
Practice Address - Fax:319-478-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IA4673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0180950Medicaid
2136169OtherPK