Provider Demographics
NPI:1790229029
Name:NEW LEAF SPECIALTY PHARMACY
Entity Type:Organization
Organization Name:NEW LEAF SPECIALTY PHARMACY
Other - Org Name:NEW LEAF SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-252-2932
Mailing Address - Street 1:3930 WESTOWN PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1032
Mailing Address - Country:US
Mailing Address - Phone:515-446-9933
Mailing Address - Fax:515-446-9917
Practice Address - Street 1:3930 WESTOWN PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1032
Practice Address - Country:US
Practice Address - Phone:515-446-9933
Practice Address - Fax:515-446-9917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK99-7975333600000X
TN62123336C0003X
IA15903336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166603OtherPK