Provider Demographics
NPI:1508858127
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:UNIVERSITY OF IOWA HOSPITALS & CLINICS/AMBULATORY CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FOR MEDICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-335-8064
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:CC101 GH
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2577
Mailing Address - Fax:319-467-5145
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:CC101 GH
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2577
Practice Address - Fax:319-467-5145
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE UNIVERSITY OF IOWA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA599333600000X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0260927Medicaid
1606447OtherNCPDP
AB4102961OtherDEA
AB4102961OtherDEA
IA0548780009Medicare NSC
IA160058Medicare PIN