Provider Demographics
NPI:1689717647
Name:TAYLOR PHARMACY REVOC TRUST
Entity Type:Organization
Organization Name:TAYLOR PHARMACY REVOC TRUST
Other - Org Name:TAYLOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:C
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:712-542-3522
Mailing Address - Street 1:122-124 NORTH 16TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-1601
Mailing Address - Country:US
Mailing Address - Phone:712-542-3522
Mailing Address - Fax:712-542-2329
Practice Address - Street 1:122 124 NORTH 16TH ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-1601
Practice Address - Country:US
Practice Address - Phone:712-542-3522
Practice Address - Fax:712-542-2329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019758000001Medicaid
IA0036194Medicaid
MI1604277Medicaid
TX1604277Medicaid
SD8530830Medicaid
NE1604277Medicaid
NE1604277Medicaid