Provider Demographics
NPI:1710995758
Name:CLINTON MEDICAL CLINIC PHARMACY INC
Entity Type:Organization
Organization Name:CLINTON MEDICAL CLINIC PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:563-242-1724
Mailing Address - Street 1:221 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-2241
Mailing Address - Country:US
Mailing Address - Phone:563-242-1724
Mailing Address - Fax:563-243-8435
Practice Address - Street 1:221 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-2241
Practice Address - Country:US
Practice Address - Phone:563-242-1724
Practice Address - Fax:563-243-8435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA753336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0148676Medicaid
0347740001Medicare ID - Type Unspecified