Provider Demographics
NPI:1659461572
Name:ALLEN MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:ALLEN MEMORIAL HOSPITAL CORPORATION
Other - Org Name:ALLEN CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKNELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:319-235-3134
Mailing Address - Street 1:146 W DALE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1901
Mailing Address - Country:US
Mailing Address - Phone:319-235-3777
Mailing Address - Fax:319-235-3134
Practice Address - Street 1:146 W DALE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1901
Practice Address - Country:US
Practice Address - Phone:319-235-3777
Practice Address - Fax:319-235-3134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA9503336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2029507OtherPK
IA1618377Medicaid
2029507OtherPK