Provider Demographics
NPI:1598215659
Name:ALLEN MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:ALLEN MEMORIAL HOSPITAL CORPORATION
Other - Org Name:PRAIRIE PARKWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-235-3660
Mailing Address - Street 1:5100 PRAIRIE PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-8155
Mailing Address - Country:US
Mailing Address - Phone:319-222-2906
Mailing Address - Fax:319-222-2996
Practice Address - Street 1:5100 PRAIRIE PKWY STE 106
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-8155
Practice Address - Country:US
Practice Address - Phone:319-222-2906
Practice Address - Fax:319-222-2996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
IA15873336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164598OtherPK
IA0220332Medicaid