Provider Demographics
NPI:1760530620
Name:OSTERHAUS PHARMACY, INC
Entity Type:Organization
Organization Name:OSTERHAUS PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTERHAUS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:563-652-5611
Mailing Address - Street 1:124 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-3034
Mailing Address - Country:US
Mailing Address - Phone:563-652-5611
Mailing Address - Fax:563-652-6242
Practice Address - Street 1:918 W PLATT ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2038
Practice Address - Country:US
Practice Address - Phone:563-652-5611
Practice Address - Fax:563-652-6242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0178608Medicaid
IA0178608Medicaid