Provider Demographics
NPI:1770656860
Name:ST ANTHONY WESTSIDE PHARMACY
Entity Type:Organization
Organization Name:ST ANTHONY WESTSIDE PHARMACY
Other - Org Name:WESTSIDE PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIEDMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-792-8231
Mailing Address - Street 1:311 S CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3038
Mailing Address - Country:US
Mailing Address - Phone:712-792-3581
Mailing Address - Fax:712-792-2124
Practice Address - Street 1:235 HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:WESTSIDE
Practice Address - State:IA
Practice Address - Zip Code:51467
Practice Address - Country:US
Practice Address - Phone:712-663-4373
Practice Address - Fax:712-663-4370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA10673336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0189316Medicaid