Provider Demographics
NPI:1497796783
Name:COVENANT MEDICAL CENTER INC
Entity Type:Organization
Organization Name:COVENANT MEDICAL CENTER INC
Other - Org Name:MERCYONE LAPORTE CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-272-7600
Mailing Address - Street 1:2710 SAINT FRANCIS DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5619
Mailing Address - Country:US
Mailing Address - Phone:319-272-5277
Mailing Address - Fax:319-272-0188
Practice Address - Street 1:601 HIGHWAY 218 N
Practice Address - Street 2:
Practice Address - City:LA PORTE CITY
Practice Address - State:IA
Practice Address - Zip Code:50651-1012
Practice Address - Country:US
Practice Address - Phone:319-342-3620
Practice Address - Fax:319-342-3617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IA8273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130099OtherPK
IA193482Medicaid