Provider Demographics
NPI:1619952926
Name:CATHOLIC HEALTH INITIATIVES-IOWA CORP
Entity Type:Organization
Organization Name:CATHOLIC HEALTH INITIATIVES-IOWA CORP
Other - Org Name:MERCYONE CLIVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-247-4278
Mailing Address - Street 1:1601 NW 114TH ST
Mailing Address - Street 2:SUITE 234
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-7007
Mailing Address - Country:US
Mailing Address - Phone:515-222-7979
Mailing Address - Fax:515-222-7976
Practice Address - Street 1:1601 NW 114TH ST
Practice Address - Street 2:SUITE 234
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7007
Practice Address - Country:US
Practice Address - Phone:515-222-7979
Practice Address - Fax:515-222-7976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-08
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
IA11933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0269373Medicaid
2030148OtherPK
0815810007Medicare NSC